Management of Herpes Zoster Ophthalmicus with Hutchinson Sign
Start oral valacyclovir 1000 mg three times daily for 7 days immediately upon recognizing shingles on the nose, and arrange urgent ophthalmology referral within 24 hours. 1
Immediate Recognition and Action
The presence of vesicles on the nose tip (Hutchinson sign) indicates involvement of the external nasal branch of the nasociliary nerve and strongly predicts ocular complications—approximately 50% of these patients will develop serious eye involvement. 2, 3 This is an ophthalmic emergency requiring immediate intervention. 4
First-Line Antiviral Therapy
Initiate systemic antiviral treatment immediately upon clinical suspicion, without waiting for laboratory confirmation or ophthalmology consultation. 1 The medication is most effective when started within 72 hours of rash onset. 5
Dosing options (choose one):
- Valacyclovir 1000 mg three times daily for 7 days (preferred) 1
- Acyclovir 800 mg five times daily for 7 days 6
- Famciclovir 500 mg three times daily for 7 days 6
Critical caveat: Adjust dosing in patients with renal impairment to prevent toxicity. 6, 1
Mandatory Ophthalmology Evaluation
All patients with herpes zoster ophthalmicus require urgent ophthalmology referral within 24 hours, regardless of whether they currently have eye symptoms. 1 The ophthalmologist will perform:
- Slit-lamp biomicroscopy to detect pseudodendritic keratitis, corneal ulceration, and stromal involvement 1
- Visual acuity measurement 6
- Assessment for uveitis (the strongest predictor of visual loss), corneal epithelial defects, and loss of corneal sensation 2
- Evaluation for late complications including corneal scarring, neovascularization, sectoral iris atrophy, and secondary glaucoma 6, 1
Adjunctive Topical Management
Apply topical antibiotics to vesicular lesions on the eyelids and nose to prevent secondary bacterial infection, which can cause severe conjunctival scarring and cicatricial ectropion. 6, 1
Avoid topical corticosteroids during the acute vesicular phase as they potentiate viral replication and prolong viral shedding. 6, 1 Corticosteroids may be considered later by the ophthalmologist for inflammatory complications (such as stromal keratitis or uveitis) only after epithelial disease has resolved and only in conjunction with continued antiviral therapy. 6, 1
Special Population Considerations
Immunocompromised patients (HIV-infected, chemotherapy recipients, chronic corticosteroid users) require more aggressive antiviral therapy with potential dose escalation and prolonged treatment duration based on clinical response. 6, 1, 5 These patients may need intravenous acyclovir for severe disease. 5
Follow-Up and Monitoring
Patients require close monitoring for:
- Acute complications (first 2-4 weeks): keratitis, uveitis, elevated intraocular pressure 6
- Subacute complications (weeks to months): corneal anesthesia, neurotrophic keratitis, persistent inflammation 6
- Chronic sequelae (months to years): dry eye, corneal scarring, postherpetic neuralgia 6, 5
Patients with positive Hutchinson sign, absent corneal sensation, corneal epithelial lesions, or uveitis at presentation require particularly vigilant follow-up as these are strong predictors of visual loss. 2
Prevention
Strongly recommend recombinant zoster vaccine (RZV) for all immunocompetent patients aged 50 years and older, with 96% efficacy in preventing herpes zoster and its complications. 6, 1 The vaccine is also recommended for immunocompromised patients aged 19 years and older. 6