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Chapter 110: Zoster Ophthalmicus

E.J. Mayeaux, Jr., MD; Richard P. Usatine, MD

Patient Story

This 5-year-old girl developed redness and pain on the right side of her forehead. Later a vesicular rash developed (Figure 110-1). She was diagnosed with herpes zoster involving the first (ophthalmic) branch of the trigeminal nerve. Note the vesicles and bullae on the forehead and eyelid and the crust on the nasal tip (Hutchinson sign). Fortunately, she did not have ocular complications and her case of zoster fully healed with systemic acyclovir and acyclovir eye ointment.

FIGURE 110-1

A 5-year-old girl with herpes zoster involving the ophthalmic branch of the trigeminal nerve. Note the vesicles and bullae on the forehead and eyelid and the crust on the nasal tip (Hutchinson sign). Fortunately, she did not have ocular complications and her case of zoster fully healed with oral acyclovir and acyclovir eye ointment. (Used with permission from Amor Khachemoune, MD.)

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Introduction

Herpes zoster is a common infection caused by varicella-zoster virus, the same virus that causes chickenpox. Reactivation of the latent virus in neurosensory ganglia produces the characteristic manifestations of herpes zoster (shingles). Herpes zoster outbreaks may be precipitated by aging, poor nutrition, immunocompromised status (Figures 110-2 to 110-4), physical or emotional stress, and excessive fatigue. Although zoster most commonly involves the thoracic and lumbar dermatomes, reactivation of the latent virus in the trigeminal ganglia may result in herpes zoster ophthalmicus (HZO) (Figures 110-1 to 110-5).

FIGURE 110-2

An HIV-positive Hispanic man with painful herpes zoster of his right forehead. His right eye was red, painful, and very sensitive to light. (Used with permission from Paul Comeau.)

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FIGURE 110-3

Acute zoster ophthalmicus of the patient in Figure 110-2. Note the conjunctival injection, corneal punctation (keratitis), and a small layer of blood in the anterior chamber (hyphema). A diagnosis of anterior uveitis was suspected based on the irregularly shaped pupil, the hyphema, and ciliary flush. A slit-lamp examination confirmed the anterior uveitis (iritis). (Used with permission from Paul Comeau.)

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FIGURE 110-4

Corneal scarring and conjunctival injection of the same patient in Figure 110-2 6 months later after being lost to follow-up. (Used with permission from Paul Comeau.)

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FIGURE 110-5

Herpes zoster ophthalmicus causing eyelid swelling and ptosis. Note the positive Hutchinson sign. (Used with permission from Richard P. Usatine, MD.)

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Synonyms

Ocular herpes zoster.

Epidemiology

  • Incidence rates of HZO complicating herpes zoster range from 8 to ...

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