CLINICAL MANAGEMENT GUIDELINES

Herpes Zoster Ophthalmicus (HZO)
Aetiology
Predisposing Factors
Symptoms
Signs
Differential Diagnosis
Management by Optometrist
Possible Management by Ophthalmologist
Evidence Base

Aetiology

  • Varicella zoster virus (VZV, a member of the herpes virus family)
  • Previous systemic infection (varicella, i.e. chickenpox)
  • Virus lies dormant (sometimes for decades) in dorsal root and cranial nerve sensory ganglia
  • Reactivation leads to zoster (shingles)
  • Herpes zoster affects 20-30% of the population at some point in their lifetime; 10-20% of these will develop HZO through involvement of the ophthalmic division of the trigeminal nerve

Predisposing Factors

  • Age
-mainly in the sixth or seventh decade, but can occur at any age
  • AIDS, immunosuppression

Symptoms

  • Pain and altered sensation of the forehead on one side
  • General malaise

Signs

Skin features
  • Unilateral painful, red, vesicular rash, progressing to crusting after 2-3 weeks; resolution often involves scarring
  • Periorbital oedema (may close the eyelids and spread to opposite side)
  • Lymphadenopathy (swollen regional lymph nodes)
  • Lesion at the side of the tip of the nose (Hutchinson’s sign) indicates twice the usual incidence of ocular complications, but these may also occur in one in three patients without the sign
Ocular lesions
  • Variable in scope and severity, chronic or recurring
  • Mucopurulent conjunctivitis, associated with vesicles on the lid margin; usually resolves within 1 week
  • Scleritis: less common; usually develops after 1 week
  • Episcleritis: occurs in around one third of cases
  • Keratitis
-punctate epithelial – early sign, within 2 days (50% of cases)
-pseudodendrites –fine, multiple stellate lesions (around 4-6 days)
-nummular – fine granular deposits under Bowman’s layer
-disciform –3 weeks after the rash (occurs in 5% of cases)
-reduced corneal sensation
-endothelial changes and KP
  • Anterior uveitis
  • Posterior segment: retinitis, 2 glaucoma, optic neuritis, optic atrophy
  • Neurological complications: cranial nerve palsies, optic neuritis, encephalitis
  • Postherpetic neuralgia: chronic and severe in about 7% patients

Differential Diagnosis

  • Ocular lesions: herpes simplex keratitis
  • Cutaneous lesions: cellulitis, contact dermatitis

Management by Optometrist

Non-pharmacological
  • Rest and general supportive measures (reassurance, support at home, good diet, plenty of fluids)
  • Advise avoidance of contact with elderly, pregnant or neonatal individuals, also those not previously exposed to VZV (who are non-immune) or immunodeficient patients
Pharmacological
  • Topical lubricants for relief of ocular symptoms
  • Pain relief: aspirin paracetamol or ibuprofen (check history for contraindications)
Management category
  • B3: management to resolution if co-managing with GP and keratitis limited to epithelium
  • A3: first aid measures and urgent referral to ophthalmologist if deeper cornea is involved or if uveitis is present
-untreated disciform keratitis can lead to scarring
-neurotrophic ulceration can lead to perforation
-herpetic uveitis requires specialist management
  • Skin lesions: emergency referral to GP for systemic anti-viral treatment

Possible Management by Ophthalmologist

  • Systemic anti-virals e.g. aciclovir, famciclovir, valaciclovir
  • Topical steroids
  • Systemic NSAIDs for scleritis
  • Surgery, e.g. tarsorrhaphy
  • Treat ocular complications
N.B: Some countries (e.g. USA, Germany) have a policy of vaccinating children against vaccinia. There is evidence that this is protective not only against vaccinia but also against herpes zoster (Civen R et al: Paed Infect Dis J 2009;28(11):954-959). Some countries (e.g. USA) offer herpes zoster vaccination for adults over 60

Evidence Base

  • Early treatment with aciclovir (within 72 hours after rash onset) reduces the percentage of eye disorders in ophthalmic zoster patients from 50% to 20-30%. This early treatment also lessens acute pain.
  • Opstelten W, Zaal M: Managing ophthalmic herpes zoster in primary care.BMJ 2005;331:147–151
(Centre for Evidence-based Medicine Level of Evidence = 2b)

Herpes Zoster Ophthalmicus (HZO)Page 1 of 4

Version 9, 15.09.2010© The College of Optometrists