Herpes zoster ophthalmicusBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b2624 (Published 13 August 2009) Cite this as: BMJ 2009;339:b2624
- Fook Chang Lam, specialist registrar in ophthalmology1,
- Allison Law, general practitioner2,
- William Wykes, consultant ophthalmologist1
- 1Department of Ophthalmology, Southern General Hospital, Glasgow G51 4TF
- 2Southbank Surgery, 17-19 Southbank Road, Kirkintilloch G66 1NH
- Correspondence to: F C Lam
- Accepted 19 March 2008
A 65 year old woman attends your practice with a two day history of a vesicular rash around her right eye. She also reports a general feeling of fatigue and malaise and has been slightly feverish over the past week. She had noticed a pain around her right eye even before the skin eruption began.
What issues you should cover
What is it and why has she got it?
After an attack of chickenpox the virus (varicella zoster) remains dormant in the body. This virus is kept in check by the immune system. However, in 20% of people the virus is reactivated, resulting in a localised painful rash with blisters (shingles). The commonest cause is a weakening of the immune system with age; most patients are aged over 50 years. Other causes include stress, fatigue, and a weakening of the immune system from other illnesses or from medical treatment (such as chemotherapy or immunosuppression).
When the eruption involves the area around the eye (the ophthalmic or first division of the trigeminal nerve), this is called herpes zoster ophthalmicus, irrespective of whether the actual eye itself is involved. Ophthalmic herpes zoster accounts for 10-25% of all cases of shingles.
Have I got the right diagnosis?
The main differential diagnosis is herpes simplex infection. In herpes simplex the patients are usually young, and the rash will not follow a dermatome, nor will it obey the midline. In herpes zoster ophthalmicus it is not unusual for the oedema to track to the other side of the face, but the rash remains dermatomal in distribution.
Can I predict who will get eye problems?
The appearance of the rash on the tip, the side, or the root of the nose indicates the involvement of the nasociliary nerve (Hutchinson’s sign) and a higher risk of ocular involvement (80%). Age, sex, and severity of skin rash are not good predictors.
What are the possible ocular complications?
These usually develop from the second week after the onset of the rash. Post-herpetic neuralgia is by far the commonest complication. Age is a potent risk factor. Antiviral drugs reduce the risk by 50%, but 20% of affected patients aged over 50 will continue to report pain six months on despite initial antiviral treatment. Less common complications are:
Lid complications—ptosis, trichiasis (ingrowing eyelashes), scarring of skin, madarosis (loss of lashes), and
Anterior segment complications—conjunctivitis, episcleritis, scleritis, stromal keratitis (inflammation of the corneal stroma, which can lead to permanent corneal scarring), neurotrophic keratitis (corneal degeneration caused by the loss or reduction of corneal innervation), anterior uveitis (inflammation of the anterior uveal tract), and raised intraocular pressure.
Rare complications include:
Posterior segment complications—acute retinal necrosis (retinal viral infection resulting in marked inflammation and retinal death), progressive outer retinal necrosis (retinal viral infection in immunosuppressed patients—progresses more rapidly but eye is less inflamed), optic neuritis, and
Motor neuropathy, such as third nerve palsy.
Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007;44(suppl 1):S1-26
Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med 2002;347:340-6, doi:10.1056/NEJMcp013211
Wareham DW, Breuer J. Herpes zoster (Clinical review). BMJ 2007;334:1211-15, doi:10.1136/bmj.39206.571042.AE
What you should do
Checking her visual acuity is vital. A normal vision and a “white” eye are very reassuring; however, be alert to the Hutchinson’s sign. Advise the patient to report any pain, reduced vision, or redness of the eyes, as this indicates the need for a repeat assessment and more detailed eye examination.
Treatment and management
Oral antivirals—Start her on treatment with an antiviral (see box).
Antiviral treatment in herpes zoster
Systemic antiviral treatment shortens the healing process of acute herpes zoster and reduces pain and other acute and chronic complications when given within 72 hours after onset of the rash.
Older patients shed the virus for longer and have a higher risk of complications and could still benefit from antivirals after this period, especially if they still have new vesicles forming.
Antivirals should be considered in all patients with herpes zoster ophthalmicus, even if they are presenting after 72 hours.
Aciclovir, valaciclovir, and famciclovir are accepted in the United Kingdom as first line treatments. They are similar in tolerability and safety, but aciclovir is usually the drug of choice on grounds of cost effectiveness. Some doctors prefer valaciclovir and famciclovir because of the superior pharmacokinetics and more convenient dosing regimens.
Standard duration of treatment is 7-10 days.
Supplementary treatment with corticosteroids may shorten the degree and duration of acute zoster pain but has no effect on the development of post-herpetic neuralgia.
Analgesia—Antivirals, analgesics, and a neuroactive agent (such as amitriptyline, gabapentin, or carbamazepine) are effective for acute pain and can be combined. Capsaicin cream to the skin is licensed for post-herpetic neuralgia after the skin lesions have healed.
Bacterial superinfection—Discourage scratching and tell her to keep the area clean with warm compresses to reduce the risk of infection. Antihistamines relieve itching. Prescribe oral antibiotics if you suspect superinfection.
Isolation—Advise her to avoid contact with individuals who have no history of chickenpox (especially pregnant women) until the vesicles have dried up (usually after several days).
Ophthalmology—A reduced visual acuity, a red eye (indicates inflammation), Hutchinson’s sign, and oculomotor palsy all warrant referral to ophthalmology. Because of the high risk of ocular complications, patients with Hutchinson’s sign should be seen within 1-2 weeks. Patients with a red eye should be seen within 24 hours to 48 hours, while patients with a red eye and reduced vision should be seen the same day or at the very latest the next morning.
Physicians and infectious diseases department—More severe disease, multiple dermatomal involvement, or recurrence suggest an underlying immunodeficiency. Patients with organ transplants and patients on systemic immunosuppression or chemotherapy need closer follow-up and should be managed in liaison with a hospital physician. Extensive cellulitis will necessitate admission for intravenous antibiotics.
Pain clinic—Established post-herpetic neuralgia can be very difficult to treat and can persist for years in 10% of patients with this condition. Neuralgia should therefore be treated aggressively. In more severe and resistant cases the patient should be referred to a pain clinic before the pain becomes chronic and established.
Cite this as: BMJ 2009;339:b2624
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.