Herpes Zoster Ophthalmicus

Herpes Zoster Ophthalmicus_top banner

The start of this story is the Varicella virus which is responsible for two conditions:

  • Chicken pox
  • Herpes Zoster (Shingles) infection

For the vast majority of people, chicken pox is an infection of childhood, which these days, is usually prevented by immunization.

For those who have had chicken pox, the virus may lay dormant in the nerves supplying the skin.

In a small proportion of individuals, the virus can reactivate and lead to the Zoster (shingles) infection, which is perhaps better known as affecting a patch of skin on the torso. 15% of cases, however, affect the eye.

Generally these reactivations occur in older people. What triggers them, is poorly understood, however people who are run-down or  those with other general health issues or are immunosuppressed, are more susceptible.

Symptoms and signs
  • The illness begins with a week or so of ‘flu like” symptoms with malaise and depression.
  • The area of the skin affected begins to become tingly and hypersensitive to touch.
  • A rash appears with flattish pink lesions turning into vesicles (clear-filled cysts) followed by pustules (filled with pus) leading to crusting and breaking down of lesions. There is associated redness of the skin, which can break down, partly due to the small blood vessels becoming involved. All of these problems occur in a well-recognized pattern. This fits the area of upper division of the ophthalmic nerve, which supplies the forehead, the lids and sometimes the tip of the nose.
  • Rarely the inside of the ear can be affected as well with transient deafness and pain.

The eyeball itself can be affected with:

  • Ulcers (pseudodendrites) appearing on the cornea.
  • There can be inflammation of the white part of the eye and the cornea.
  • There may be inflammation of the inside of the eye (uveitis).
  • Rarely the nerves responsible for moving the eye can become involved, leading to a palsy and double vision.
  • Rarely the optic nerve can be affected with profound loss of vision.

The symptoms associated with all of this can increase from mild irritation to marked photophobia (intolerance of light), redness, and loss of vision. The most debilitating symptom is the neuralgia – nerve pain.

Treatment

If caught within the first 72 hrs of the rash:

  • Treatment with a high dose of the antiviral agent Aciclovir or Valaciclovir as tablets for seven days, has been shown to hasten resolution and reduce the severity of the infection.
  • An antibiotic ointment should be applied to the vesicles to prevent secondary infection. Once the crusts have gone and the skin is healing, a mild steroid cream can be applied, in combination with skin massage to help relieve the neuralgia.
  • Antibiotic drops may be given for the eye to prevent secondary infection and to help lubricate.
  • Steroid drops may well be required to settle the redness and photophobia. They also help reduce corneal scarring and prevent sight loss.
  • Pain relief may include paracteomol with a mild opiate. Sometimes tricycles antidepressants such as amitriptyline, or the anticonvulsant carbamazepine have been shown to be helpful.

This illness is not over in a few days, and even after the inflammation has settled a marked post-viral malaise, (feeling of being unwell), may be present for several weeks.

Chronic (longer term) Eye Problems

Because the virus causes damage to nerves and the structure of the eye, there can be ongoing problems with:

  • Episodic inflammation and chronic ulceration. It is sometimes necessary to remain on long-term drops supervised by your ophthalmologist.
  • Antibiotic drops may be given for the eye to prevent secondary infection and to help lubricate.
  • Steroid drops may well be required to settle the redness and photophobia. They also help reduce corneal scarring and prevent sight loss.

This illness is not over in a few days, and even after the inflammation has settled, a marked post-viral malaise, (feeling of being unwell), may be present for several weeks.

Courtesy Matt Poe

This condition can be debilitating and potentially sight-threatening, although this is rare.
Early use of antiviral tablets and topical steroids often save the situation. 
These pictures are extreme examples.