Herpes zoster ophthalmicus

Background

• Occurs when VZV is reactivated in the ophthalmic division (V1) of trigeminal nerve
• 50% of cases associated with ocular involvement
  • Highly suggested by vesicles at tip of nose (Hutchinson's sign)
• Consider immunocompromise in pts <40yrs

Clinical Features

• Prodrome of HA, malaise, photophobia, fever
• Unilateral pain or hypesthesia in V1 distribution
• Hyperemic conjunctivitis, episcleritis, lid droop

Diagnosis

• Zoster in distribution of V1
• Slit-lamp exam:
  • Pseudodendrite (poorly staining mucous plaque w/ no epithelial erosion
    • In contrast to HSV which has true dendrite w/ epithelial erosion and staining
  • Cell and flare

Differential Diagnosis

Conjunctivitis Types

• Viral conjunctivitis
  • Epidemic keratoconjunctivitis
  • Herpes zoster ophthalmicus
  • Herpes simplex keratitis
• Bacterial conjunctivitis
  • Gonorrheal conjunctivitis
  • Chlamydia conjunctivitis
• Allergic conjunctivitis
• Caustic keratoconjunctivitis

Treatment

• Cool compresses/lubrication drops
• Topical antibiotics to skin to prevent secondary infection
• Acyclovir indicated for rash <1wk duration
  • Treatment - acyclovir IV 10 mg/kg q8hrs x7-10 days
  • OR famiciclovir PO 500 mg q8hrs x14 days
  • OR valacyclovir PO 1g q8hrs
• Prevention of reactivation
  • Acyclovir PO 500 mg 5x per day
• Ophtho consultation regarding steroid use