Herpes zoster ophthalmicus | |
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Other names | Ophthalmic zoster |
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Herpes zoster ophthalmicus | |
Specialty | Ophthalmology |
Symptoms | Rash of the forehead, swelling of the eyelid, pain and red eye |
Complications | visual impairment, increased pressure within the eye, chronic pain, stroke |
Causes | Reactivation of varicella zoster virus |
Risk factors | Poor immune function, psychological stress, older age |
Diagnostic method | Based on symptoms |
Prevention | Herpes zoster vaccine |
Medication | Antiviral pills such as acyclovir, steroid eye drops |
Frequency | Up to 125,000 per year (US) [1] |
Herpes zoster ophthalmicus (HZO), also known as ophthalmic zoster, is shingles involving the eye or the surrounding area. Common signs include a rash of the forehead with swelling of the eyelid. There may also be eye pain and redness, inflammation of the conjunctiva, cornea or uvea, and sensitivity to light. Fever and tingling of the skin and allodynia near the eye may precede the rash. Complications may include visual impairment, increased pressure within the eye, chronic pain, [1] [2] [3] and stroke. [4]
The underlying mechanism involves a reactivation of the latent varicella zoster virus (VZV) within the trigeminal ganglion supplying the ophthalmic nerve (the first division of the trigeminal nerve). Diagnosis is generally based on signs and symptoms. [2] Alternatively, fluid collected from the rash may be analyzed for VZV DNA using real-time PCR. This test is rapid, easy to perform, and is highly sensitive and specific method for diagnosing this condition. [5]
Treatment is generally with antiviral pills such as acyclovir. Steroid eye drops and drops to dilate the pupil may also be used. The herpes zoster vaccine is recommended for prevention in those over the age of 50. [2] HZO is the second most common manifestation of shingles, the first being involvement of skin of the thorax.[ citation needed ] Shingles affects up to one half million people in the United States per year, of which 10% to 25% is HZO. [1] [3]
Anterior uveitis develops in 40–50% of people with HZO within 2 weeks of the onset of the skin rashes.[ citation needed ] Typical HZO keratitis at least mild iritis, especially if Hutchinson's sign is positive for the presence of vesicles upon the tip of the nose.
Features: [8]
This non-granulomatous iridocyclitis is associated with:
HZO uveitis is associated with complications such as iris atrophy and secondary glaucoma are not uncommon. Complicated cataract may develop in the late stages of the disease.
HZO is due to reactivation of VZV within the trigeminal ganglion. The trigeminal ganglion give rise to the three divisions of cranial nerve V (CN V), namely the ophthalmic nerve, the maxillary nerve, and the mandibular nerve. VZV reactivation in trigeminal ganglion predominantly affects the ophthalmic nerve, for reasons not clearly known. The ophthalmic nerve gives rise to three branches: the supraorbital nerve, the supratrochlear nerve, and the nasociliary nerve. Any combination of these nerves can be affected in HZO, although the most feared complications occur with nasociliary nerve involvement, due to its innervation of the eye.[ citation needed ] The supraorbital and supratrochlear nerves mainly innervate the skin of the forehead.[ citation needed ] The frontal nerve is more commonly affected than the nasociliary nerve or lacrimal nerve. [8]
Treatment is usually with antivirals such as acyclovir, valacyclovir, or famcyclovir by mouth. [2] There is uncertainty as to the difference in effect between these three antivirals. [9] Antiviral eye drops have not been found to be useful. [1] These medications work best if started within 3 days of the start of the rash. [3]
Cycloplegics prevent synechiae from forming.
Ramsay Hunt syndrome type 2, commonly referred to simply as Ramsay Hunt syndrome (RHS) and also known as herpes zoster oticus, is inflammation of the geniculate ganglion of the facial nerve as a late consequence of varicella zoster virus (VZV). In regard to the frequency, less than 1% of varicella zoster infections involve the facial nerve and result in RHS. It is traditionally defined as a triad of ipsilateral facial paralysis, otalgia, and vesicles close to the ear and auditory canal. Due to its proximity to the vestibulocochlear nerve, the virus can spread and cause hearing loss, tinnitus, and vertigo. It is common for diagnoses to be overlooked or delayed, which can raise the likelihood of long-term consequences. It is more complicated than Bell's palsy. Therapy aims to shorten its overall length, while also providing pain relief and averting any consequences.
Varicella zoster virus (VZV), also known as human herpesvirus 3 or Human alphaherpesvirus 3 (taxonomically), is one of nine known herpes viruses that can infect humans. It causes chickenpox (varicella) commonly affecting children and young adults, and shingles in adults but rarely in children. VZV infections are species-specific to humans. The virus can survive in external environments for a few hours.
Shingles, also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. Two to four days before the rash occurs there may be tingling or local pain in the area. Other common symptoms are fever, headache, and tiredness. The rash usually heals within two to four weeks; however, some people develop ongoing nerve pain which can last for months or years, a condition called postherpetic neuralgia (PHN). In those with poor immune function the rash may occur widely. If the rash involves the eye, vision loss may occur.
Keratitis is a condition in which the eye's cornea, the clear dome on the front surface of the eye, becomes inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following symptoms: pain, impaired eyesight, photophobia, red eye and a 'gritty' sensation. Diagnosis of infectious keratitis is usually made clinically based on the signs and symptoms as well as eye examination, but corneal scrapings may be obtained and evaluated using microbiological culture or other testing to identify the causative pathogen.
Aciclovir (ACV), also known as acyclovir, is an antiviral medication. It is primarily used for the treatment of herpes simplex virus infections, chickenpox, and shingles. Other uses include prevention of cytomegalovirus infections following transplant and severe complications of Epstein–Barr virus infection. It can be taken by mouth, applied as a cream, or injected.
Postherpetic neuralgia (PHN) is neuropathic pain that occurs due to damage to a peripheral nerve caused by the reactivation of the varicella zoster virus. PHN is defined as pain in a dermatomal distribution that lasts for at least 90 days after an outbreak of herpes zoster. Several types of pain may occur with PHN including continuous burning pain, episodes of severe shooting or electric-like pain, and a heightened sensitivity to gentle touch which would not otherwise cause pain or to painful stimuli. Abnormal sensations and itching may also occur.
Valaciclovir, also spelled valacyclovir, is an antiviral medication used to treat outbreaks of herpes simplex or herpes zoster (shingles). It is also used to prevent cytomegalovirus following a kidney transplant in high risk cases. It is taken by mouth.
A dermatome is an area of skin that is mainly supplied by afferent nerve fibres from the dorsal root of any given spinal nerve. There are 8 cervical nerves , 12 thoracic nerves, 5 lumbar nerves and 5 sacral nerves. Each of these nerves relays sensation from a particular region of skin to the brain.
The ophthalmic nerve (CN V1) is a sensory nerve of the head. It is one of three divisions of the trigeminal nerve (CN V), a cranial nerve. It has three major branches which provide sensory innervation to the eye, and the skin of the upper face and anterior scalp, as well as other structures of the head.
The nasociliary nerve is a branch of the ophthalmic nerve (CN V1) (which is in turn a branch of the trigeminal nerve (CN V)). It is intermediate in size between the other two branches of the ophthalmic nerve, the frontal nerve and lacrimal nerve.
Brivudine is an antiviral drug used in the treatment of herpes zoster ("shingles"). Like other antivirals, it acts by inhibiting replication of the target virus.
Idoxuridine is an anti-herpesvirus antiviral drug.
Corneal ulcer, also called keratitis, is an inflammatory or, more seriously, infective condition of the cornea involving disruption of its epithelial layer with involvement of the corneal stroma. It is a common condition in humans particularly in the tropics and in farming. In developing countries, children afflicted by vitamin A deficiency are at high risk for corneal ulcer and may become blind in both eyes persisting throughout life. In ophthalmology, a corneal ulcer usually refers to having an infection, while the term corneal abrasion refers more to a scratch injury.
Chickenpox, or chicken pox, also known as varicella, is a highly contagious, vaccine-preventable disease caused by the initial infection with varicella zoster virus (VZV), a member of the herpesvirus family. The disease results in a characteristic skin rash that forms small, itchy blisters, which eventually scab over. It usually starts on the chest, back, and face. It then spreads to the rest of the body. The rash and other symptoms, such as fever, tiredness, and headaches, usually last five to seven days. Complications may occasionally include pneumonia, inflammation of the brain, and bacterial skin infections. The disease is usually more severe in adults than in children.
A cold sore is a type of herpes infection caused by the herpes simplex virus that affects primarily the lip. Symptoms typically include a burning pain followed by small blisters or sores. The first attack may also be accompanied by fever, sore throat, and enlarged lymph nodes. The rash usually heals within ten days, but the virus remains dormant in the trigeminal ganglion. The virus may periodically reactivate to create another outbreak of sores in the mouth or lip.
Hutchinson's sign is a clinical sign which may refer to:
Diffuse lamellar keratitis (DLK) is a sterile inflammation of the cornea which may occur after refractive surgery, such as LASIK. Its incidence has been estimated to be 1 in 500 patients, though this may be as high as 32% in some cases.
Herpetic simplex keratitis is a form of keratitis caused by recurrent herpes simplex virus (HSV) infection in the cornea.
Nummular keratitis is a feature of viral keratoconjunctivitis. It is a common feature of adenoviral keratoconjunctivitis, as well as approximately 1/3rd of cases of Herpes Zoster Ophthalmicus infections. It represents the presence of anterior stromal infiltrates. Unilateral or bilateral subepithelial lesions of the cornea may be present. Slit lamp examination reveals multiple tiny granular deposits surrounded by a halo of stromal haze. After healing, residual 'nummular scars' often remain. Disciform keratitis occurs in 50% of individuals with Nummular keratitis, but Nummular keratitis always precedes Disciform keratitis.
Neurotrophic keratitis (NK) is a degenerative disease of the cornea caused by damage of the trigeminal nerve, which results in impairment of corneal sensitivity, spontaneous corneal epithelium breakdown, poor corneal healing and development of corneal ulceration, melting and perforation. This is because, in addition to the primary sensory role, the nerve also plays a role maintaining the integrity of the cornea by supplying it with trophic factors and regulating tissue metabolism.