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Herpes Zoster Ophthalmicus

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Original article contributed by:

John B. Cason MD

All contributors:
Brad H. Feldman, M.D., Vatinee Y. Bunya, MD,
MSCE, Maria A. Woodward, MD, Koushik Tripathy,
MD (AIIMS), FRCS (Glasgow), Michael T Yen,
MD, Sezen Karakus, MD, John B. Cason MD

Assigned editor:
Sezen Karakus, MD, Shannon S. Joseph, M.D.

Review:
Assigned status Up to Date

by Michael T Yen, MD on May 25, 2021.

Disease Entity

Diagnosis

Management
General treatment
Skin rash treatment should prevent bacterial superinfection.
With careful examination inflammation in all layers of the eye
should be ruled out and treated with antivirals and steroids if
indicated. When a skin rash is the only clinical sign, follow-up
care must be directed to ruling out any ocular manifestations
that may develop.

Medical therapy
Oral acyclovir 800 mg PO five times daily for 7 to 10 days is the
standard treatment. Alternatively, famciclovir 500 mg PO TID
or valacyclovir 1000mg PO TID can be used. If the systemic
condition warrants or if the patient is unable to tolerate food
by mouth then acyclovir 5-10 mg/kg IV q8 for 5 days may be
utilized.

Topical steroids (e.g. prednisolone acetate 1%) should be used

for interstitial keratitis and uveitis. For episodes of scleritis,
retinitis, choroiditis, and optic neuritis, systemic steroids by
mouth or intravenous administration should be strongly
considered.

For increased intraocular pressure commonly found in herpes

trabeculitis, topical steroids should be administered as well as
aqueous suppressants (e.g. timolol, brimonidine, dorzolamide,
acetazolamide).

Pain should be treated with narcotics if warranted.

Neuropathic pain responds well to amitriptyline 25 mg PO
QHS and can decrease the incidence of postherpetic neuralgia.
Capsaicin cream applied to the rash may decrease pain as
well. [13] Pregabalin 150mg /day in divided doses may alleviate
pain due to acute herpetic neuralgia.

Medical follow up
Depending on the ocular findings and severity the patient
should be monitored every 1 to 7 days during the acute
episode. Monitoring every 3-12 months afterward may be
helpful to monitor for delayed sequelae such as ocular
hypertension, cataract, and cornea scarring. If there is any
concern about future exacerbations, viral prophylaxis should
be considered with acyclovir 400 mg PO BID.

Surgery
Cornea transplantation is sometimes required for lesions that
cause severe cornea thinning and loss of structural integrity of
the eye. Scars that are visually significant and refractory to
medical therapy and/or hard contact lenses may require
transplantation. Vitrectomy/Retina detachment surgery may
be performed especially in cases of acute retinal necrosis
(ARN). Glaucoma filtration surgery is sometimes performed if
there are difficulties with maintaining optimum intraocular
pressure. If the intraocular inflammation and/or steroid
treatment causes a cataract then cataract surgery may be
performed when the disease process is quiescent.

Surgical follow up
Depending on the type of surgery performed, the patient
should be closely monitored for severe inflammation
commonly associated with herpes after surgical procedures.
Viral prophylaxis with antiviral therapy and steroids should be
strongly considered.

Complications
Zoster skin manifestations in the eyelids can affect the deep
dermis. Therefore, cicatrix can result in ptosis, lid scarring,
ectropion, and entropion. Scleritis can cause scleral, limbal, and
corneal atrophy. Inflammation in the cornea, optic nerve,
retina, and choroid could result in permanent vision loss.
Corneal scars commonly affect the vision requiring hard
contact lens or cornea transplantation interventions.
Postherpetic neuralgia occurs in 36.6% of patients over the age
of 60 and in 47.5% over the age of 70.[11]

Prognosis
Prognosis is greatly variable and dependent on long-term
sequelae. Long-term vision loss, need for surgery, and long-
term antiviral prophylaxis are all possible.

Additional Resources

References

Categories:
Articles Cornea/External Disease
Oculoplastics/Orbit

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This page was last edited on October

11, 2021, at 11:18.

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