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Anterior Segment Grand Rounds

Case 1

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More about herpes zoster

Herpes zoster, commonly known as shingles, is caused by the reactivation of the varicella-zoster virus (which is the same virus that causes chickenpox). Although anyone who has had chickenpox is at risk to develop herpes zoster, it usually occurs in persons over age 50. It is unknown what reactivates the virus, but suspect triggers are things that weaken the immune system--including illness, fatigue, emotional or physical stress, chemotherapy, some medications, and poor nutrition.

The virus remains dormant in the body's nerve root cells. When reactivated, it travels along nerve fibers and settles in areas of the skin--often causing severe pain, redness, a rash of vesicles (small, fluid-filled blisters), itching, and numbness.

Herpes zoster ophthalmicus occurs where there is reactivation of the virus along the V trigeminal nerve. A rash can appear on the eyelids. Herpes zoster can also cause redness of the conjunctiva, corneal scarring (increasing the risk of bacterial infection), iritis or uveitis. It can affect the retina or optic nerve as well. Patients complain of pain, redness, swelling, photophobia, and blurred vision.

Ocular Signs:
  • Rash: Hutchinson's rule
  • Eyelid
  • Conjunctiva
  • Episclera/sclera
  • Cornea: PEK, pseudodendrite, stromal infiltrates, disciform keratitis, mucous plaques, neurotrophic keratitis
 Other complications:
  • Iritis
  • Glaucoma-trabeculitis
  • Optic neuritis
  • Pupil anomalies--Horner's syndrome
  • EOM palsies
  • Cataracts
  • Posterior segment involvement--chorioretinitis; acute retinal necrosis syndrome and progressive outer retinal necrosis syndrome
  • Post-herpetic neuralgia
lesion Lid margin ulceration. Lesion caused by herpes zoster.

[view video]
skin and vesicular lesions on face Classic skin and vesicular lesions caused by herpes zoster.
pseudodendrite with zoster Pseudodentrite with herpes zoster. Appears "ropey"; not as delicate as Herpes simplex.
neurotropic keratopathy This obvious epithelial defect is neurotrophic keratopathy caused by retinal surgery. Although beta blocker use and retinal surgery are the most common causes of neurotrophic keratopathy, it can also occur with herpes zoster (and Herpes simplex). Neurotrophic keratopathy is rare and difficult to treat.

[view video]

Treatment and Management

  • Early diagnosis and early oral antiviral are keys to initial management.
    Options:
    • Zovirax (acyclovir), 800mg 5x/day for 7 days (generic available)
    • Famvir (famciclovir), 500mg tid for 7 days
    • Valtrex (valacyclovir), 1000mg tab tid for 7 days
  • Remember acute signs, but don't forget delayed signs.
  • Watch IOPs!
  • Topical steroids OK.

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Go to: Anterior segment grand rounds CE table of contents

URL: http://www.opt.indiana.edu/ce/antseg/zoster.htm
Revised: November 20, 2004
IU Optometry home page: http://www.opt.indiana.edu/
Comments (content): Dr. Vic Malinovsky at malinovs@indiana.edu
Comments: Web Administrator
Page design and coding: Terri Greene
Copyright © 2004, The Trustees of Indiana University