Herpes Zoster Ophthalmicus: History, Examination, and Management
Clinical Presentation and History
Herpes zoster ophthalmicus (HZO) occurs when varicella-zoster virus reactivates in the ophthalmic division of the trigeminal nerve, affecting approximately 4-20% of all herpes zoster cases and requiring urgent ophthalmologic evaluation due to significant risk of vision loss. 1
Key Historical Features to Elicit:
- Prodromal symptoms: Periorbital pain, burning, or paresthesia preceding rash onset 2
- Rash characteristics: Vesicular eruption following dermatomal distribution of V1 (ophthalmic division) 2
- Timing: Duration since rash onset (critical for antiviral efficacy—treatment most effective within 72 hours) 3, 4
- Risk factors: Age >50 years, immunosuppression status (HIV, transplant, chemotherapy), declining VZV-specific cellular immunity 1, 4
- Visual symptoms: Blurred vision, photophobia, eye pain, or decreased visual acuity 5
Essential Examination Findings:
- Hutchinson's sign: Vesicles on tip/side of nose indicating nasociliary nerve involvement and higher risk of ocular complications 2
- Ocular manifestations (occur in ~50% of HZO patients): 1
- Conjunctivitis (most common)
- Keratitis (including pseudodendrites, stromal keratitis)
- Anterior uveitis/iritis with sectoral iris atrophy
- Secondary glaucoma
- Optic neuropathy (uncommon but serious)
- Slit-lamp biomicroscopy: Essential for detecting corneal involvement, anterior chamber inflammation 3
- Intraocular pressure measurement: Screen for secondary glaucoma 5
Immediate Management: Antiviral Therapy
Initiate oral antiviral therapy immediately—ideally within 72 hours of rash onset—with valacyclovir 1000 mg three times daily for 7 days as first-line treatment in immunocompetent adults. 3, 6
Antiviral Regimen Selection:
For immunocompetent patients (choose one): 3, 6, 7
- Valacyclovir 1000 mg PO three times daily × 7 days (preferred)
- Acyclovir 800 mg PO five times daily × 7 days (alternative)
- Famciclovir 500 mg PO three times daily × 7 days (alternative)
For immunocompromised patients: 3
- More aggressive therapy required with potential dose adjustments
- Consider intravenous acyclovir for complicated cases
- Treatment duration may need extension beyond 7 days based on clinical response 5
Critical caveat: In immunosuppressed patients with severe disseminated VZV, consider temporarily discontinuing immunosuppressive therapy; restart only after commencing anti-VZV therapy and resolution of skin vesicles 3
Renal Dosing Adjustments:
Exercise caution in patients with impaired renal clearance—dose reduction mandatory based on creatinine clearance 5, 6. For creatinine clearance 30-49 mL/min with herpes zoster, reduce valacyclovir to 1000 mg twice daily 6.
Adjunctive Topical Management
What TO Use:
- Topical antibiotics to vesicular lesions: Prevent secondary bacterial infection and severe conjunctival scarring (can lead to cicatricial ectropion) 5
What NOT to Use:
- Topical antivirals alone are ineffective for VZV conjunctivitis and should not be used as monotherapy 5, 3
- Topical corticosteroids are absolutely contraindicated during active epithelial viral infection—they potentiate viral replication and worsen infection 3
When Corticosteroids May Be Considered:
Only after epithelial disease has resolved, topical corticosteroids at minimum effective dose may be used for inflammatory complications (stromal keratitis, uveitis) under direct ophthalmologist supervision 5. Use corticosteroids with poor ocular penetration (fluorometholone, loteprednol) to minimize IOP elevation and cataract risk 5.
Pain Management
Achieving painlessness is the primary therapeutic goal beyond preventing ocular complications. 4
- Appropriately dosed analgesics combined with neuroactive agents (e.g., amitriptyline) given concurrently with antiviral therapy 4
- Systemic corticosteroids may shorten acute zoster pain duration but have no essential effect on preventing postherpetic neuralgia 4
- Early referral to pain specialist recommended for refractory cases 4
- Oral acyclovir reduces intensity of postherpetic neuralgia—only 13% of treated patients experience this complication versus higher rates in untreated patients 8
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation including: 3
- Interval history
- Visual acuity measurement
- Slit-lamp biomicroscopy
- Intraocular pressure measurement (especially if corticosteroids used)
For patients on corticosteroid therapy: Regular IOP monitoring and pupillary dilation to evaluate for glaucoma and cataract formation 3
Long-term monitoring: Up to 25% of HZO patients with ocular involvement develop chronic or recurrent disease requiring prolonged treatment and/or long-term prophylaxis 1. Late sequelae include dry eye and corneal anesthesia with neurotrophic keratitis 5.
Prevention of Future Episodes
Vaccination against herpes zoster is the most effective prevention strategy. 1
- Recombinant adjuvanted vaccine (RZV/Shingrix) is more effective than live-attenuated vaccine (ZVL) for preventing both HZ and HZO 1
- Vaccination is recommended even in patients with prior HZO, though data on effectiveness for preventing recurrent disease are limited 1
- Physician recommendation is the strongest predictor of vaccination—actively encourage vaccination in all eligible patients 1
Critical Pitfalls to Avoid
- Delaying antiviral therapy beyond 72 hours—efficacy dramatically decreases 3, 4, 2
- Using topical corticosteroids during active epithelial infection—this worsens viral replication 3
- Failing to obtain urgent ophthalmology consultation—50% develop ocular disease requiring specialist management 1, 2
- Relying on topical antivirals alone—these are ineffective for VZV 5, 3
- Inadequate pain management—combination therapy with neuroactive agents is essential 4