Zoster Ophthalmicus

Kristin M. Hammersmith



• Acute, painful, vesicular eruption distributed along the ophthalmic branch of the trigeminal nerve (1).

• Ocular inflammation without characteristic rash: Zoster sine herpete (2).



• 200,000 new cases per year in the US.

• 1% life time risk (3).


• Increasing age.

• Immune compromise (i.e., HIV, cancer, immunosuppression) (4).


• CDC recommendation (2008)—routine vaccination of all individuals 60 years or older with Varicella Zoster Vaccination (Zostavax®), including those with prior history of herpes zoster or chronic medical conditions.

• The vaccine is not licensed for the treatment of acute HZ or post herpetic neuralgia (PHN), or for the prevention of HZ in patients aged younger than 60 years (5).


• Reactivation of latent virus from trigeminal ganglia with viremia and spread of virus from sensory axons to skin.

• Age-related decline in varicella-zoster virus specific cell mediated immunity increases susceptibility to viremia (5).



• Painful vesicular eruption in a single dermatome.

• Fever, malaise, headache, and pain in the affected dermatome.

• Affective disorder: Anorexia, lassitude, mood changes, antisocial behavior, depression, and insomnia (6).


• Rash involving the V1 dermatome evolving from an erythematous lesion with macules, papules and vesicles with pustules and crusts developing subsequently.

• Slit-lamp examination.

– Early:

– Eyelid: Hyperemia, edema, ptosis.

– Conjunctiva: Hyperemia, petechial hemorrhages, vesicles, pseudodendrites, papillae, follicles, pseudomembranes.

– Sclera/episclera: Limbal vasculitis, sclerokeratitis, posterior scleritis.

– Cornea:

– Epithelium: Pseudodendrites, punctate epithelial keratitis.

– Stroma: Nummular stromal keratitis, disciform keratitis (7).

– Iris/uvea: Segmental iris edema, granulomatous keratouveitis with keratic precipitates (8), secondary glaucoma (9).

– Retina/optic nerve: Retinal perivasculitis, ischemic optic neuritis, necrotizing retinopathy.

– Late (1 month after rash):

Eyelid: Cicatricial entropion/ectropion, trichiasis.

Conjunctiva: Hyperemia, pseudomembranes.

Sclera/episclera: Limbal vasculitis, sclerokeratitis, posterior scleritis.


Epithelium: Delayed pseudodendrites (mucous plaque keratitis), punctate epithelial keratitis, neurotrophic ulceration, band keratopathy (10).

Stroma: Nummular stromal keratitis, disciform keratitis, lipid deposition, anterior and posterior stromal scarring, chronic edema (7).

Iris/Uvea: Segmental iris atrophy, granulomatous keratouveitis with KP, secondary glaucoma.

Retina: Acute retinal necrosis (ARN), progressive outer retinal necrosis (PORN).

• Neuroophthalmic examination.

– Extraocular muscles: Transient EOM palsy and diplopia (11).

– Cranial nerves: CN III, IV, or VI can be involved indicating vasculitis within the orbital apex (orbital apex syndrome) or brainstem dysfunction (12).

– Acute pain: Characterized as lancinating, burning, aching, and/or itching.

– Post-herpetic neuralgia (PHN)—pain lasting more than 1 month after disease onset. Characterized as constant or intermittent aching or burning, sudden lancinating pain, allodynia (pain from nonpainful stimuli), and/or a constant or intermittent itch (13).



No laboratory work up is necessary unless there is a high index of suspicion for HIV.


Initial approach

Slit-lamp examination including intraocular pressure assessment, corneal sensation, and dilated funduscopic examination.

Follow-up & special considerations

• Starting oral antiviral therapy shortens the duration of acute pain, virus shedding, rash, acute, and late-onset anterior segment complications, and the incidence and severity of PHN (12).

• Depending on severity of ocular inflammation, patient should be re-evaluated within 5–7 days and frequency of follow-up visits should be dictated by severity of slit-lamp findings.


Treatment with valacyclovir in severe immunocompromise has been associated with thrombocytopenic purpura/hemolytic uremic syndrome and is therefore not FDA approved for use in this subset of patients.

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Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on Zoster Ophthalmicus

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