Does tingling on the tip of the nose during a shingles (herpes zoster) outbreak indicate potential involvement of the eye or retina?

Tingling on the Nose in Shingles: Implications for Ocular Involvement

Tingling on the tip of the nose during a shingles outbreak is a significant warning sign for potential eye involvement and should prompt immediate ophthalmological evaluation to prevent vision-threatening complications.

Understanding the Connection Between Nasal Tingling and Ocular Shingles

• Tingling on the tip of the nose during herpes zoster (shingles) is known as Hutchinson's sign, which indicates involvement of the nasociliary branch of the trigeminal nerve 1, 2
• This sign strongly suggests that the virus may affect the eye because the same nerve branch supplies both the tip of the nose and parts of the eye 2
• When herpes zoster affects the ophthalmic division of the trigeminal nerve, it's called Herpes Zoster Ophthalmicus (HZO) 2

Potential Ocular Complications

• Herpes zoster affecting the eye can cause various complications including:

  • Conjunctivitis (inflammation of the conjunctiva) 1
  • Keratitis (inflammation of the cornea) 1
  • Epithelial keratitis that may be punctate or pseudodendritic 1
  • Uveitis (inflammation of the uvea) 1
  • Retinitis (inflammation of the retina) 1
  • Secondary glaucoma 3
  • Corneal scarring and late corneal anesthesia or dry eye 1

• In recurrent disease (shingles), keratitis of the epithelium or stroma can lead to:

  • Subsequent scarring 1
  • Corneal anesthesia 1
  • Dry eye syndrome 1
  • Vision loss in severe cases 2

Clinical Course and Management

• Varicella zoster virus (VZV) becomes latent in cerebral or posterior root ganglia after primary infection (chickenpox) and can reactivate decades later as shingles 3
• The trigeminal ganglion is one of the most commonly involved ganglia in herpes zoster 3
• Daily ophthalmological review is necessary during acute illness when eye involvement is suspected 2
• Treatment should include:
  • Non-preserved ocular lubricants every 2 hours throughout the acute illness 2
  • Consideration of topical corticosteroid drops to reduce ocular surface damage 2
  • Broad-spectrum topical antibiotics if corneal fluorescein staining or ulceration is present 2
  • Systemic antiviral therapy (acyclovir, valacyclovir, or famciclovir), ideally started within 72 hours of rash onset 4, 5

Prevention and Risk Factors

• The recombinant zoster vaccine (RZV) is recommended for:
  • Immunocompetent adults aged 50 years or older 2
  • Immunocompromised patients 19 years and older 2
  • Adults who previously received the older zoster vaccine live (ZVL) 2
• Risk factors for developing shingles include:
  • Advanced age 3, 5
  • Immunosuppression (HIV infection, chemotherapy, malignancies, chronic corticosteroid use) 3, 5
  • Declining cellular immune response 3

Important Considerations

• Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits immediate referral to an ophthalmologist 4
• Antiviral medications are most effective when started within 72 hours after the onset of the rash 4, 5
• Even in the absence of pain (which can occur in some patients), the presence of a rash along with tingling on the nose should prompt evaluation for potential eye involvement 6