Herpes zoster ophthalmicus
Herpes zoster ophthalmicus is reactivation of latent varicella-zoster virus in the ophthalmic (V1) division of the trigeminal ganglion, producing a dermatomal vesicular rash that can involve the cornea, uvea, and optic nerve. Diagnosis is clinical, and first-line treatment is oral valacyclovir or famciclovir started within 72 hours of rash onset, with intravenous acyclovir for severe or immunocompromised disease.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Herpes zoster ophthalmicus (HZO) is reactivation of latent varicella-zoster virus (VZV) within the ophthalmic (V1) division of the trigeminal ganglion, producing a unilateral, dermatomal vesicular…
- Epidemiology
Age: Zoster overall becomes markedly more common after age 50 and continues to rise through the 60s, 70s, and 80s as VZV-specific cell-mediated immunity declines with age.
- Risk factors
Advancing age: Declining VZV-specific cell-mediated immunity is the dominant risk factor for reactivation, including HZO.
- Pathophysiology
Primary VZV infection (chickenpox) seeds sensory ganglia, including the trigeminal ganglion, where the virus establishes lifelong latency.
- Clinical features
Prodrome: Burning, tingling, or aching pain in a V1 distribution, often with malaise and low-grade fever, precedes the rash by 1 to 4 days.
- Differential diagnosis
Herpes simplex keratitis: A true dendritic ulcer with terminal bulbs on fluorescein staining, but without the preceding dermatomal vesicular rash of HZO.
- Diagnosis
The diagnosis is made clinically: A unilateral, dermatomal vesicular rash confined to the V1 distribution with a preceding neuralgic prodrome is diagnostic in most cases; little else produces grouped vesicles in a strict dermatomal pattern.
- Management
First, start oral antiviral therapy within 72 hours of rash onset in an immunocompetent adult with localized disease: Valacyclovir 1000 mg PO three times daily for 7 days, first choice.
- Complications
Keratitis and scarring: Epithelial, stromal, and neurotrophic keratitis can progress to permanent corneal scarring, with impaired healing from reduced corneal sensation persisting for months.
- Prognosis
Acute course: Most immunocompetent patients treated promptly have resolution of the rash within 2 to 4 weeks, but ocular complications can recur or smolder for months.
- Prevention
Vaccination: The recombinant zoster vaccine, given as a 0.5 mL intramuscular two-dose series with the second dose 2 to 6 months after the first (as short as 1 to 2 months in immunocompromised…
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Herpes zoster (shingles)
Herpes zoster is reactivation of latent varicella-zoster virus from a sensory ganglion, producing a painful, dermatomal vesicular rash that does not cross the midline, most common in adults older than 60 years and in immunosuppressed hosts; diagnosis is clinical, confirmed by VZV PCR when needed, and antiviral therapy started within 72 hours of rash onset shortens the illness and reduces postherpetic neuralgia.
- Herpes simplex keratitis
Herpes simplex keratitis is reactivation of latent HSV along the trigeminal nerve causing a corneal dendritic ulcer with pain, photophobia, and decreased corneal sensation. Diagnosis is clinical on slit lamp with fluorescein staining; treatment is a topical or oral antiviral, and topical corticosteroids are contraindicated in active epithelial disease.
- Uveitis
Uveitis is inflammation of the uveal tract, classified by anatomic location as anterior, intermediate, posterior, or panuveitis and by systemic association such as HLA-B27 spondyloarthritis, sarcoidosis, or Behcet disease. Anterior uveitis presents with a painful red eye and photophobia diagnosed at the slit lamp, while posterior uveitis presents with painless floaters or vision loss, and treatment is topical corticosteroid for anterior disease escalating to systemic corticosteroid and steroid-sparing immunosuppression for recurrent, severe, or posterior-segment disease.
- Viral keratitis
Non-herpetic viral keratitis, overwhelmingly adenoviral, produces copious watery discharge, severe irritation, and preauricular lymphadenopathy that starts unilateral and spreads to the second eye. Management is supportive and infection-control focused; chronic subepithelial infiltrates are the vision-affecting sequela that sometimes needs ophthalmology-directed topical corticosteroid.
- Acute angle-closure glaucoma
Acute angle-closure glaucoma is a pupillary-block emergency in which sudden closure of the iridocorneal angle blocks aqueous outflow, causing severe eye pain, halos, and rapidly rising intraocular pressure that can blind the eye within hours if not treated. Diagnosis is clinical plus tonometry and gonioscopy; treatment is immediate topical and systemic IOP-lowering therapy followed by laser peripheral iridotomy.
- Trigeminal neuralgia
Trigeminal neuralgia causes brief, unilateral, electric shock-like facial pain in the maxillary or mandibular trigeminal distribution, often triggered by light touch, most commonly from neurovascular compression of the nerve; contrast-enhanced brain MRI evaluates for a structural or demyelinating cause, and first-line treatment is carbamazepine, with microvascular decompression or ablative procedures for medically refractory disease.