Complications of Herpes Zoster Ophthalmicus
Larry W. Womack, MD, Thomas J. Liesegang, MD
\s=b\ Of 86 patients with herpes zoster
ophthalmicus seen at the Mayo Clinic,
Rochester, Minn, from 1975 to 1980, 61
had some form of ocular involvement.
Corneal disease was seen in 47, uveitis in
37, postherpetic neuralgia in 15, scleritis
in three, and ocular motor palsies in three.
No case of optic nerve or retinal involve-
ment was found. Of serious concern were
four patients with neurologic complica-
tions, including two with contralateral
hemiplegia and two with segmental cere-
bral arteritis. Because the neurologic
complications occur several months after
the episode of herpes zoster ophthalmi-
cus, the association is often overlooked
and the opportunity to treat with cortico-
steroids for systemic effect is missed.
(Arch Ophthalmol 1983;101:42-45)
Tnvolvement of the ophthalmic
-*- branch of the trigeminal nerve by
herpes zoster ranges in frequency
from 8% to 56% in various series.1-2 A
Mayo Clinic study (Rochester, Minn)
that reviewed records between 1935
and 1949 indicated a frequency of
16.3% of trigeminal herpes zoster.3
One published series showed ocular
involvement in 50% of cases of herpes
zoster ophthalmicus.4 Ophthalmic
herpes zoster is of interest to the
clinician not only because of its poten¬
tial for causing substantial visual and
socioeconomic disability but also
because of its potential threat to life
imposed by associated cerebrovascu-
lar attacks.5·6 We reviewed all recent
cases of herpes zoster ophthalmicus
seen at the Mayo Clinic to put the
reported complications into proper
perspective.
METHODS
The computerized files of the Mayo Clin¬
ic were surveyed for all patients in whom
herpes zoster ophthalmicus had been diag¬
nosed between 1975 and 1980. Included
were all patients who had acute disease or
who were referred for subacute or chronic
disease. The history was reviewed for clin¬
ical aspects of ocular disease, systemic
disease, radiation or immunosuppressive
therapy, previous episodes of herpes zos¬
ter, and exposure to varicella. The compli¬
cations, the quality of the postherpetic
neuralgia, and the treatment directed to
herpes zoster ophthalmicus were evalu¬
ated.
RESULTS
Epidemiology
We identified 86 patients (53
Accepted for publication Feb 3, 1982.
From the Department of Ophthalmology,
Mayo Clinic and Mayo Foundation, Rochester,
Minn.
Reprint requests to Mayo Clinic, Rochester,
MN 55905 (Dr Liesegang).
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women and 33 men) with herpes zos¬
ter ophthalmicus. Of these patients,
67 were examined in the Department
of Ophthalmology and 19 had only
apparent skin involvement and were
not referred for ophthalmologic eval¬
uation. Sixty-four patients had acute
disease, and 22 were referred for sub-
acute or chronic disease. The age
range of the patients was 20 to 88
years (average age, 65 years) (Table
1). Fifty-six patients were in the sev¬
enth or eighth decade of life. The right
eye was involved in 38 patients and
the left eye was involved in 48. No
patient had bilateral involvement or
previous episodes of herpes zoster
ophthalmicus. One patient reported a
recent exposure to varicella before the
onset of the zoster lesions.
Ocular Complications
Many patients had a preeruptive
pain in the eye or in the distribution
of the trigeminal nerve, although the
diagnosis of preeruptive herpes zoster
rarely was made. The most common
pattern of skin distribution was con¬
comitant eruption along three cutane¬
ous branches (frontal, lacrimal, and
nasociliary) of the ophthalmic divi¬
sion of the trigeminal nerve. Ocular
complications could not be prognosti¬
cated on the basis of the involvement
of the nasociliary branch of the oph¬
thalmic division; the severity of the
disease did not correlate with the
number of branches involved.
Of the 64 patients with acute dis¬
ease, 18 (28% ) had only eyelid vesicles
without the development of ocular or
adnexal disease. Of the total series of
86 patients, 61 (71%) had ocular
involvement. Patients with this dis¬
ease have a predilection for dermal
inflammation, and extensive lid scar¬
ring was seen in 11 patients in this
series. The ocular complications are
given in Table 2. Surgical repair fre¬
quently was necessary for the lid
abnormalities.
The corneal manifestations of her¬
pes zoster ophthalmicus are diverse
and were noted in 47 of our patients in
either the acute or the chronic stage
of the disease. Some patients demon¬
strated more than one manifestation.
Acute epithelial keratitis was an early
manifestation in 19 patients and was
detected as a pseudodendrite in seven.
Inexperienced examiners frequently
mistook these lesions for superim¬
posed herpes simplex keratitis, but
the lesions were raised, multiple, and
peripherally located, they stained
with rose bengal, and the zoster virus
could be cultured from them. A non¬
specific punctate epitheliitis was seen
in 12 patients, and multiple small
mucous plaques were seen in two.
Acute anterior stromal infiltrates
were seen in seven patients within one
to two weeks after the onset of herpes
zoster. The infiltrates appeared just
beneath Bowman's membrane, were
frequently multiple, and often re¬
sponded to topically administered 1%
prednisolone acetate. One of the more
dramatic forms of corneal disease was
a disciform keratitis, which mani¬
fested either as a fairly rapid periph¬
eral or central infiltration or as ede¬
ma. This complication, seen in 17
patients, had a variable time onset
from a few weeks to several months
after the initial episode of the disease.
The inflammation was responsive to
1% prednisolone acetate but had a
tendency to recur in conjunction with
late vascularization and deposition of
lipid, crystalline stromal changes,
deeper involvement of the cornea, and
occasionally stromal ulcération.
In one patient in this series, den-
drites similar to the early pseudoden-
drites were noted three months after
the initial episode of herpes zoster.
These lesions were culture negative,
persistent for months, wandering, and
unresponsive to topically applied 1%
prednisolone acetate. They eventually
cleared without any sequelae. Involve¬
ment of the sclera and adjacent cor¬
nea (sclerokeratitis) was seen in two
patients and caused vascularization,
scarring, and deposition of lipid in the
cornea.
Neurotrophic keratitis was seen in
tenpatients; the onset varied from
one to several months after the dis¬
ease was originally diagnosed. Corne¬
al sensation was absent, and the
lesions consisted of punctate epitheli¬
al erosions, poor corneal luster, tear-
film abnormalities, indolent corneal
erosions, and occasionally band kera-
topathy. This condition must be dis¬
tinguished from the epithelial ulcér¬
ation associated with stromal inflam¬
mation, which can be treated with
topically administered 1% predniso¬
lone acetate. Neurotrophic keratitis
occasionally responded to insertion of
soft contact lenses but most frequent¬
ly necessitated tarsorrhaphy. In this
series of patients, no superimposed
bacterial or fungal infections were
noted. One patient had a corneal per¬
foration and concomitant severe rheu-

Table 1.—Age and Sex Distribution
of 86 Patients With Herpes Zoster
Ophthalmicus
No. of Patients
Age, yr_ M involved in two patients and the sixth
20-29 1 1
30-39
2 2
40-49 1 2
50-59 3 8
60-69
70-79
14
9
10
22
80-89
3 8
Total 33 53
Average 64.1 65.2
matoid arthritis; whether the perfora¬
tion was due to the herpes zoster
ophthalmicus or to the marginal cor¬
neal disease related to the rheumatoid
arthritis was unclear.
One patient had recurrent episcleri-
tis that responded to topically admin¬
istered 1% prednisolone acetate.
Scleritis was found in three patients,
two of whom had nodular anterior
scleritis and one of whom had posteri¬
or involvement. No cases of dacryoad-
enitis were recorded, but two patients
in this series had unilateral canalicu-
lar scarring without bacterial infec¬
tion; this complication apparently was
directly related to the attack of herpes
zoster ophthalmicus. These two
patients, a 20-year-old woman and a
70-year-old woman, were not given
antiviral medication. The younger
patient did not respond to probing but
did well with a dacryocystorhinosto-
my and placement of a Jones tube.
Uveitis was seen in 37 patients
(43% of the total series), with exten¬
sive keratic precipitates in three and
extensive posterior synechiae in four.
The uveitis was usually prolonged for
months and necessitated careful
adjustment of the dose of topically
applied 1% prednisolone acetate. Sec¬
torial atrophy of the iris resulting in
ill-defined margins developed in 15
patients. Stromal damage was rare,
but damage to the sphincter and tor¬
sion of the iris developed in three
patients.
A secondary glaucoma was present
in ten patients, all of whom had asso¬
ciated uveitis. Four patients were
treated early and vigorously with top¬
ically applied 1% prednisolone ace¬
tate, and all responded with resolu¬
tion of the increased intraocular pres¬
sure. Two patients had persistently
increased IÖP, and one had a visual
field loss from persistent glaucoma
even after the herpes zoster apparent¬
ly became quiescent.
Cataracts developed during the
course of the disease in seven patients,
all of whom had chronic uveitis. Six of
the seven had posterior subcapsular
cataracts and were given topically
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applied 1% prednisolone acetate for
more than three months.
Neuro-ophthalmic complications
were seen in seven patients. Cranial
nerve palsies were detected in three
patients: the fourth cranial nerve was
cranial nerve in one patient. Although
palsies of the third cranial nerve have
been reported most frequently in the
literature,7 we found no patient with
this involvement in our series.
A contralateral hemiplegia oc¬
curred within a few months after her¬
pes zoster ophthalmicus in two
patients. One of these patients also
had a facial nerve palsy that partially
resolved, and the other patient
became comatose and died. Autopsy
confirmed the presence of granuloma-
tous angiitis of the cerebral vessels.
Two additional patients were seen
within a few months after the original
attack of herpes zoster ophthalmicus
with various neurologic manifesta¬
tions, including paresthesias, tran¬
sient ischemie attacks, and aphasia.
Cerebral angiography disclosed seg¬
mentai cerebral arteritis in both. The
association of herpes zoster ophthal¬
micus and these serious neurologic
manifestations was overlooked ini¬
tially because these complications
characteristically occur a few months
after the original episode. None of
these patients was treated with pred-
nisone when the neurologic complica¬
tions developed.
Postherpetic neuralgia persisted in
15 patients; the pain was mild in ten
and moderate to severe in five. The
age of these patients ranged from 21
to 83 years and averaged 63 years. The
more severe neuralgias were seen in
the older patients. In two of the
patients with severe postherpetic neu¬
ralgia, segmental cerebral arteritis
developed. Four of the patients with
postherpetic neuralgia had been
treated with prednisone early in the
course of the disease.
Complications of herpes zoster oph¬
thalmicus necessitated 11 ocular sur¬
gical procedures in eight patients. Six
patients had tarsorrhaphy for neuro¬
trophic keratitis. The other proce¬
dures were cryotherapy for trichiasis,
ectropion repair, entropion repair,
dacryocystorhinostomy with place¬
ment of a Jones tube (for canalicular
obstruction), and a penetrating kera-
toplasty (in a patient with severe
rheumatoid arthritis and perforation
related to marginal thinning shortly
after an episode of herpes zoster oph¬
thalmicus).
During the period of study, 24
patients (28%) had a substantial
visual loss associated with herpes zos¬
ter ophthalmicus. This loss was mild
(visual acuity 20/50 to 20/200) in 14
patients and severe (worse than 20/
200) in ten. The causes of poor visual
acuity were stromal scarring (14
patients), neurotrophic keratitis
(eight), cataract (seven), band kerato-
pathy (one), corneal perforation with
penetrating keratoplasty (one), and
glaucoma (one). In some patients,
more than one factor was incrimi¬
nated.
Associated Conditions
Although lymphomas are frequent¬
ly associated with herpes zoster and
may lead to disseminated zoster, no
lymphoma was identified in our 86
patients with herpes zoster ophthal¬
micus. Other malignant lesions, how¬
ever, were seen in 13 patients (Table
3). One of the four patients with ade-
nocarcinoma of the breast also had
ipsilateral orbital métastases that
were treated with irradiation. All of
these tumors were in the remote his¬
tory except in the three patients with
brain tumors and the one patient with
lung carcinoma, all of whom died of
causes related to their malignant
lesion. In no patient in this series was
the ophthalmic zoster the initial sign
of a serious medical disorder.
Four patients had different forms
of vasculitis, and all were treated with
prednisone. None had progression of
the zoster or severe ophthalmic com¬
plications attributable to the cortico-
steroid pretreatment. Additionally,
four patients had other medical
conditions present concurrently with
the herpes zoster ophthalmicus.
Of the total series of 86 patients,
five had been given prednisone before
the onset of herpes zoster ophthalmi¬
cus. One additional patient had prior
irradiation to the orbit, and one
patient was on immunosuppressive
therapy for a malignant lesion. One
patient had a history of ocular trauma
immediately before the onset of her¬
pes zoster ophthalmicus, and one had
a history of sunburn in the immediate
prior period.
Therapy
Only 36 of the 64 patients (56%)
who had acute disease required or
received therapy for the herpes zoster
ophthalmicus. Four of the 11 patients
who were treated with prednisone
early in the course of the disease
subsequently had moderate posther¬
petic neuralgia. No important differ¬
ence in the complications was noted
between those who had been and those
who had not been treated with predni¬
sone but the number of patients
involved was small. Topically applied
1% prednisolone acetate was used in
26 patients; the results were beneficial
 Table 2.—Ocular Complications in 86 Patients With
Complication
Lid involvement
Entropion with trichiasis of upper lid
Ptosis
Cicatricial ectropion with exposure of
Scarring of both upper and lower lids
Total
Corneal involvement
Acute epithelial keratitis
Pseudodendritic keratitis
Punctate epithelial keratitis
Mucous plaques
Total
Acute anterior stromal infiltrates
Disciform keratitis
Sclerokeratitis
Neurotrophic keratitis
Late dendritic keratitis
Perforation
Total
Scierai involvement
Episcleritis (recurrent)
Scleritis
Total
Canalicular scarring
Uveitis
Diffuse
Localized
Sectorial iris atrophy
Total
Glaucoma (secondary)
Persistent
Neuro-ophthalmic involvement
Cranial nerve palsy
Contralateral hemiplegia
Segmental cerebral arteritis
Total
Postherpetic neuralgia
'Some patients had more than
when use was judicious and when
close follow-up surveillance was
maintained. Twenty-three patients
received topically applied cycloplegic
agents.
COMMENT
These 86 cases of herpes zoster oph¬
thalmicus seen at the Mayo Clinic
between 1975 and 1980 add no new
complications of the disease to the
literature but serve to highlight some
of the important clinical features and
the potential for major visual impair¬
ment, neurologic complications, and
even death from this usually mild
disease. Frequently, these patients
are quite uncomfortable and difficult
to examine, and the associated find¬
ings reported in the literature are a
tribute to the diligence of the examin¬
ing ophthalmologist.
This series of patients with herpes
zoster ophthalmicus shows a predomi¬
nance of involvement in the left eye
and also in female patients and a peak
incidence in the seventh and eighth
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Table 3.—Associated Conditions
Herpes Zoster Ophthalmicus in 86 Patients With
Herpes Zoster Ophthalmicus
No. of Patients
No. of
Condition Patients
0
Lymphoma
cornea Cancer
Adenocarcinoma of
breast 4
11 Bladder carcinoma 3
Prostatic carcinoma 1
Lung carcinoma 1
Thyroid carcinoma 1
Astrocytoma of brain 2
Meningioma of brain 1
Total 13
19· Vasculitis
Systemic lupus
erythematosus 1
Temporal arteritis 1
Rheumatoid arthritis 1
10 "Vasculitis" 1
Total 4
Addison's disease 1
47· Asthmatic patient taking
corticosteroids 1
Multiple sclerosis 1
Ocular pemphigoid 1
Total 21
the total series. Neurotrophic and dis-
ciform keratitis were especially fre¬
33 quent. Pseudodendrites, found in sev¬
en patients, are of particular interest
in that they must be distinguished
37· from the dendrite of herpes simplex
10 and the varicella zoster virus may be
2 cultured from them. The early pseudo¬
dendrites, anterior stromal infil¬
trates, disciform keratitis, and scierai
keratitis all are corticosteroid sensi¬
tive.13 Thus, the distinction of the ker¬
atitis from that of herpes simplex is
clinically pertinent.1416 Superimposed
bacterial, fungal, or herpes simplex
one manifestation of involvement. keratitis must be diligently sought,
especially in patients being given top¬
decades of life. Other series have ically applied 1% prednisolone ace¬
shown a male predominance or an tate. One of our patients had periph¬
equal distribution between the sexes eral corneal ulcération and subse¬
and a peak incidence in the fourth quent perforation, but he had severe
decade or the fifth through seventh rheumatoid arthritis and was taking
decades of life.4-8'10 Of the 64 patients prednisone. The cause of the corneal
with acute herpes zoster ophthalmi¬ perforation in this patient was not
cus, 46 (72%) had ocular or adnexal clear, although Mondino et al" have
disease, a larger proportion than the described peripheral corneal ulcéra¬
50% usually quoted in the litera¬ tions in herpes zoster ophthalmicus.
ture.4·" Uveitis was seen in 37 of our
In contrast to the herpes simplex patients (43%); the iritis may be dif¬
skin lesions, the herpes zoster virus fuse or local, and the iris may have
has a predilection for deeper involve¬ vascular dilatation or eruptive le¬
ment of the dermis, and subsequent sions.18 Posterior synechiae occasion¬
contraction scars are more frequent ally occur. Corneal edema or striate
and necessitate reconstructive plastic keratopathy can be seen during the
surgical procedures. Topically applied episode of iritis. Pigment iris atrophy
cutaneous corticosteriods, antibiotics, in herpes zoster ophthalmicus is sec¬
or concentrated antiviral agents (such torial and causes ill-defined margins
as idoxuridine in 40% dimethyl sulf- of the iris. Although stromal damage
oxide12) are used in an attempt to is rare, sphincter damage can occur.
prevent some of this scarring, Fluorescein angiography demon¬
although these modalities were used strates occlusion of iris vessels at the
in only a few of our patients. sites of atrophy.18 In contrast, the iris
Corneal involvement of an acute or atrophy associated with herpes sim¬
a chronic nature was seen in 55% of plex causes sharply defined borders
 and scalloped margins, and iris arte¬
ries are patent in the involved areas.
Marsh et al18 found sectorial iris atro¬
phy in 25% of their patients, some¬
what more than the 17% found in our
series. Increased IOP was seen in ten
of our patients (9%), but only one
patient had glaucomatous cupping of
the optic disc and visual field loss. The
elevation of IOP is believed to be due
to inflammation of the trabecular
meshwork and accumulation of in¬
flammatory debris from accompany¬
ing uveitis.1920 The IOP must be moni¬
tored at all examinations because it
frequently increases abruptly, but
early treatment with topically applied
1% prednisolone acetate will yield a
response.
Scleritis associated with herpes zos¬
ter ophthalmicus may be nodular or
brawny and may occur acutely two to
three months after the onset of the
disease. It may extend to the cornea
and cause a characteristic vascular¬
ization and deposition of lipid, espe¬
cially temporally or nasally. Scleritis
is usually associated with uveitis.
Various affections of the retina and
optic nerve, including central retinal
vein occlusion, central retinal artery
occlusion, necrotizing retinitis, de¬
layed thrombophlebitis, optic neuro¬
pathy, and localized arteritis with or
without exudates, have been de¬
scribed.2125 We found no cases involv¬
ing the retina, although hazy media
may mask its appearance.
Ocular motor palsies were rare in
our series, unlike the series reported
by Marsh et al7 in which a 31% inci¬
dence was found when these disorders
were diligently sought. Additionally,
1. Hope-Simpson RE: The nature of herpes
zoster: A long-term study and a new hypothesis.
Proc R Soc Med 1965;58:9-20.
2. Lewis GW: Zoster sine herpete. Br Med J
1958;2:418-421.
3. De Moragas JM, Kierland RR: The outcome
of patients with herpes zoster. Arch Dermatol
1957;75:193-196.
4. Edgerton AE: Herpes zoster ophthalmicus:
Report of cases and review of literature. Arch
Ophthalmol 1945;34:40-62, 114-153.
5. Acers TE: Herpes zoster ophthalmicus with
contralateral hemiplegia. Arch Ophthalmol
1964;71:371-376.
6. Laws HW: Herpes zoster ophthalmicus
complicated by contralateral hemiplegia. Arch
Ophthalmol 1960;63:273-280.
7. Marsh RJ, Dulley B, Kelly V: External ocu-
lar motor palsies in ophthalmic zoster: A review.
Br J Ophthalmol 1977;61:677-682.
8. Scott TFM: Epidemiology of herpetic infec-
tions. Am J Ophthalmol 1957;43:134-147.
9. Burgoon CF Jr, Burgoon JS, Baldridge GD:
The natural history of herpes zoster. JAMA
1957;164:265-269.
10. Kass EH, Aycock RR, Finland M: Clinical
evaluation of aureomycin and chloramphenicol
in herpes zoster. N Engl J Med 1952;246:167\x=req-\
172.
11. Duke-Elder S: System of Ophthalmology. St
Downloaded From: http://archopht.jamanetwork.com/ by a University of Calgary User on 05/28/2015
those investigators frequently found
contralateral or bilateral muscle pal¬
sies. The third cranial nerve is usually
the most frequently involved, and the
recovery is usually complete.
Of particular concern in our series
were two cases of contralateral hemi-
plegia and two additional cases of
angiographically demonstrated seg¬
mentai cerebral arteritis. These
events occurred within a few months
after the initial episode of herpes zos¬
ter ophthalmicus. One patient with
contralateral hemiplegia subsequent¬
ly died of cerebral hemorrhage. The
pathologic basis of these processes is a
granulomatous angiitis of the cere¬
bral arteries or internal carotid
artery continuous with the trigeminal
ganglion.25 28 This pattern of vasculitis
is similar to the reported ocular and
orbital pathologic features.29 The two
patients with segmental cerebral
arteritis had varied neurologic com¬
plications that ultimately resolved.
These life-threatening complications
were not initially recognized to be due
to herpes zoster ophthalmicus in these
patients. Certainly, such patients may
potentially be benefited with the use
of prednisone. Postherpetic neuralgia
was severe in two of these patients.
Postherpetic neuralgia was re¬
ported in 15 patients (17%). The most
severe cases were in elderly patients.
The data are insufficient to comment
on the role of the early use of predni¬
sone in preventing this complication.
Although 21 of our patients (24% )
had associated systemic diseases, 13
of these conditions were cancers that
had occurred several years before the
attack of herpes zoster ophthalmicus.
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It was notable that in the five-year
period of our study, no cases of associ¬
ated lymphoma or leukemia and no
disseminated herpes zoster ophthal¬
micus was seen.
The inflammatory lesions of herpes
zoster ophthalmicus frequently re¬
spond well to topically applied 1%
prednisolone acetate. This drug has a
definite role in the treatment of sever¬
al aspects of the corneal, scierai, or
uveal inflammation and in the ocular
hypertensive response. Judicious use
can help eliminate some of the visual
complications, but the drug must fre¬
quently be used heavily, monitored
closely, and administered for pro¬
longed periods; moreover, the dosage
must be carefully tapered. The recog¬
nition of superimposed bacterial, fun¬
gal, or herpes simplex disease is
important, as is the recognition of
certain conditions that will not
respond to topically applied 1% pred¬
nisolone acetate, such as neurotrophic
keratitis. The complications from
nerve damage and the secondary scar¬
ring of tissue are difficult to treat.
The ocular morbidity is related to the
consequences of this nerve damage
and scarring. Systemic morbidity
must be remembered, especially if the
patient later has neurologic com¬
plaints. The role of prednisone in the
treatment of herpes zoster ophthalmi¬
cus cannot be ascertained from this
study. The role of systemic antiviral
agents is currently being evaluated.
Key Words.—Contralateral hemiplegia;
herpes zoster; herpes zoster ophthalmicus;
neurotrophic keratitis; postherpetic neu¬
ralgia; segmental cerebral arteritis; zos¬
ter.
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rhagic retinopathy. Am J Ophthalmol 1951;34:45\x=req-\
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complicating herpes zoster ophthalmicus. Br J
Ophthalmol 1973;57:344-346.
23. Hesse RJ: Herpes zoster ophthalmicus
associated with delayed retinal thrombophlebi-
tis. Am J Ophthalmol 1977;84:329-331.
24. Jensen J: A case of herpes zoster ophthal-
micus complicated with neuroretinitis. Acta Oph-
thalmol 1948;26:551-555.
25. Schwartz JN, Cashwell F, Hawkins HK, et
al: Necrotizing retinopathy with herpes zoster
ophthalmicus: A light and electron microscopical
study. Arch Pathol Lab Med 1976;100:386-391.
26. Gilbert GJ: Herpes zoster ophthalmicus
and delayed contralateral hemiparesis: Relation-
ship of the syndrome to central nervous system
granulomatous angiitis. JAMA 1974;229:302-304.
27. Rosenblum WI, Hadfield MG, Young HF:
Granulomatous angiitis with preceding varicella
zoster. Ann Neurol 1978;3:374-375.
28. Linnemann CC Jr, Alvira MM: Pathogene-
sis of varicella-zoster angiitis in the CNS. Arch
Neurol 1980;37:239-240.
29. Naumann G, Gass JDM, Font RL: Histopa-
thology of herpes zoster ophthalmicus. Am J
Ophthalmol 1968;65:533-541.