What are the implications of Herpes Zoster Ophthalmicus (HZO) presenting with only redness, without vesicles?

From the Guidelines

Herpes zoster ophthalmicus (HZO) without vesicles, presenting only with redness, requires immediate medical attention and treatment to prevent complications. The diagnosis of HZO can be supported by the characteristic dermatomal distribution of redness along the ophthalmic branch of the trigeminal nerve, as described in the conjunctivitis preferred practice pattern 1. According to the most recent and highest quality study, treatment should begin with oral antiviral therapy, such as valacyclovir 1000mg three times daily for 7-10 days, or alternatives like acyclovir 800mg five times daily for 7-10 days 1. Some key points to consider in the management of HZO include:

• Pain management with acetaminophen or NSAIDs is recommended, and in severe cases, gabapentin or pregabalin may be needed for neuropathic pain.
• Patients should seek immediate ophthalmological evaluation to assess for ocular involvement, which occurs in about 50-70% of HZO cases.
• The absence of vesicles doesn't rule out HZO, as the virus can cause inflammation and nerve damage without forming the typical blisters.
• Early treatment is crucial to prevent complications like postherpetic neuralgia, scarring, and vision loss, even in cases without vesicles, as noted in the study 1. It's also important to note that HZO can lead to severe conjunctival scarring from secondary infection, which can result in cicatricial ectropion, as mentioned in the study 1. Additionally, the study 1 highlights the importance of prompt treatment to prevent late sequelae, such as dry eye and corneal anesthesia with neurotrophic keratitis. Overall, the management of HZO without vesicles requires a comprehensive approach, including oral antiviral therapy, pain management, and immediate ophthalmological evaluation to prevent complications and improve patient outcomes.

From the Research

Herpes Zoster Ophthalmicus without Vesicle

• Herpes zoster ophthalmicus (HZO) is a subset of herpes zoster (HZ) that involves the ophthalmic division of the fifth cranial trigeminal nerve 2
• HZO can present with various ocular manifestations, including conjunctivitis, keratitis, and uveitis, even in the absence of vesicles 2, 3
• The diagnosis of HZO is typically based on the presence of a rash or vesicles in the distribution of the ophthalmic division of the trigeminal nerve, but it can also be suspected in patients with ocular symptoms and a history of HZ 4, 3

Treatment and Management

• Antiviral medications, such as valaciclovir and acyclovir, are effective in reducing the severity and duration of HZO, including ocular complications 5, 3, 6
• Valaciclovir has been shown to be at least as effective as acyclovir in preventing ocular complications of HZO, and has a simpler dosing schedule 3
• Famciclovir is also a effective treatment option for HZO, and has been shown to reduce the risk of pain and ocular complications 6

Clinical Presentation

• HZO can present with redness and ocular symptoms, even in the absence of vesicles 2, 3
• The clinical presentation of HZO can vary, and may include conjunctivitis, keratitis, uveitis, and other ocular complications 2, 3
• A high index of suspicion is necessary to diagnose HZO, especially in patients with ocular symptoms and a history of HZ 4, 3