What is Herpes Zoster Ophthalmicus?

HZO

What is herpes zoster ophthalmicus (HZO)?

It is a viral disease that involves skin of head and eyes and involves the ophthalmic branch of trigeminal nerve (CN-5).

What causes herpes zoster ophthalmicus?

It is caused by varicella-zoster virus, which is the same virus that causes chicken-pox. The infection occurs when the latent herpes zoster virus in the neurosensory ganglions is reactivated. Old age, weakened immune system (HIV), emotional or physical stress and fatigue precipitate the reactivation of varicella-zoster virus.

What are sign and symptoms of herpes zoster ophthalmicus?

Caused by a virus herpes zoster, HZO presents with flu-like illness, low grade fever, headache, malaise, maculopapular rash over the head and blepharoconjunctivitis. However, vesicular rash over the dermatome of first division of cranial nerve 5 (CN5-V1) is the hallmark of HZO. Inflammation, edema and ptosis of upper eye-lid are commonly seen.

What tests should be carried out for herpes zoster ophthalmicus?

Most of the time, no tests are needed as clinical findings are diagnostic. However, some tests can be carried out to confirm or exclude the diagnosis:

• Antigen detection by immunofluorescence
• Viral swabs of vesicle for culture
• VZV DVA PCR

What is the treatment of herpes zoster ophthalmicus?

Antiviral therapy is the main stay of management of HZO.

For systemic illness:

Tablet Acylex (Acyclovir) 800 mg – Take one tablet five times a day for seven days.

[Acyclovir should be administered within 3 days (72 hours) of the presentation of ophthalmic features. After 72 hours, the effect of acyclovir is diminished.]

For topical use:

Acylex Ointment (Topical antiviral ointment) – Apply over the affected areas for two times a day.

Fusiderm ointment (Antibiotic/antibacterial ointment) – Apply over the affected areas three times a day.

For eye care:

Lequix eye drops (contains levofloxacin) - One drop four times a day for 20-30 days

Sanitovir (antiviral eye ointment) - Apply four times a day for 20-30 days.

Cold compresses – relieves pain

Lidocain cream 5% - topically used to relieve pain

NSAIDS (conventional pain-killers) – Intramuscular or oral use

What are the complications of herpes zoster ophthalmicus?

If timely management is not offered, HZO can lead to serious complications like:

• Epithelial, stromal, and disciform keratitis (persistent vasculitis may lead to eurotrophic keratitis, mucus plaque keratitis and lipid degeneration of corneal scars)
• Dry eye
• Anterior uveitis
• Necrotizing retinitis
• Cranial nerve palsies (usually facial nerve; however, oculomotor (CN-3), trochlear (CN-4), and abducens (CN-6) nerve palsies may also occur
• Lagophthalmos
• Postherpetic neuralgia (PHN)
• Raised intraocular pressure
• Orbital apex syndrome
• Vision loss
• Optic neuritis [especially retrobulbar optic neuritis- if optic neuritis occurs, methylprednisolone (Solu Medrol) 1000mg intravenous or intramuscular for 3 to 5 days plus prednisolone (Deltacortil) 60mg per day for 10 days are advised along with antiviral therapy and other measures].

How to prevent herpes zoster infection?

The patient with active varicella-zoster infection should avoid contact with susceptible persons such as premature infants and immunocompromised persons, until the lesions/vesicles are crusted.

Varicella-zoster vaccine (attenuated VZV) is safe, effective and well-tolerable to reduce the subsequent attacks and decrease the morbidity and mortality of zoster virus. It is a lyophilized preparation of attenuated VZV. A single dose of 0.65 ml is injected subcutaneously in the region of deltoid muscle. Each 0.65 ml of zoster vaccine contains 19400 PFU (plaque-forming-unit) of Oka stain of VZV. Do not inject intravenously or intramuscularly. Booster dose of zoster vaccine is not recommended.

Reference:

• Sanjay S, Huang P, Lavanya R. Herpes zoster ophthalmicus. Curr Treat Options Neurol 2011;13(1):79-91.
• Shaikh S, Cristopher N. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66(9):1723-30. 
• Gelb LD. Preventing herpes zoster through vaccination. Ophthalmology 2008;115(2 Suppl):S35-8.

 A Case Summary of the patient with the same condition

Name:(Patient)

Date of birth: 15/03/1977 (Age: 37 years)

Gender: Male

Residence: Punjab, Pakistan 

Medical Summary:
No improvement was observed. The patient was advised to have CT scan brain and right eye visual field. Both CT scan brain and right eye visual field were normal.

Final Diagnosis: Post Herpes Zoster Ophthalmicus (HZO) Retrobulbar Optic Neuritis of left side, leading to complete left loss of vision

Clinical and Treatment Summary: Mr. Muhammad Saeed experienced severe pain behind the left eye and small sized vesicular rashes over the left side of forehead on February 17, 2014. The local doctor took it for some allergy and gave some anti-allergic drugs. The rashes increased in size spreading around the left eye. Left eye was swollen and closed. A skin specialist and an ophthalmologist were consulted on 19/02/2014. Diagnosis of Herpes Zoster Ophthalmicus (HZO) was made. The skin specialist put the patient on the following drugs:

Acylex 800 mg x P/O x 5 times a day (for 10 days)

Acylex Ointment x BD

Fusiderm ointment x TDS

The eye specialist advised no drug as eye examination was normal.

On 24/02/2014, rashes subsided but the patient experienced vision loss and immediately was examined by the eye specialist and the diagnosis of HZO Retrobulbar Optic Neuritis of left side, leading to complete left loss of vision was confirmed. The patient was put on the following drugs in addition to the above mentioned medication: 

Lequix eye drops x 4 times a day (for 30 days)

Sanitovir x 4 times a day (for 30 days)

Deltacortil 5mg x 5 x TDS (continued for 3 days) 

The unsatisfied patient attended another eye specialist on 27/02/2014. And, he got the following treatment: 

Solu Medrol 1000mg x IV (in 1000ml N/S) x (for 3 days)

Deltacortil 60mg x OD (for 10 days) 

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Keywords: Herpes zoster ophthalmicus, HZO, Trigeminal nerve, Varicella-zoster virus, Keratitis, Blepharoconjunctivitis, Vision loss, Antiviral therapy, Acyclovir. Neurosensory ganglion