Herpes Zoster Ophthalmicus
Usually this entity presents with classic findings that make diagnosis simple; however... HZO may easily be confused with more common and benign eye pathology - Thomas Catron MD
image by: Dr Pawan Prasher
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For Your Eyes Only
Herpes Zoster Ophthalmicus is a reactivation of a latent Varicella Zoster Virus that specifically involves the eye. The reactivation often occurs during immunocompromised states which allows latent virus in the dorsal root ganglia of sensory nerves to begin viral replication and spread via peripheral axons.
Diagnosis is based on two characteristic findings; herpetic lesions on the eyelids, forehead, or elsewhere within the V1 dermatome, and ocular findings. Symptoms can vary but are often quite painful. Some patients experience a prodrome of tingling sensation prior to the appearance of a zoster dermatitis. HZO can also present initially as flu-like symptoms before developing into…
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Pharmacotherapy options include oral acyclovir, 800 mg 5 times a day; oral valacyclovir, 1000 mg 3 times a day; and oral famciclovir, 500 mg 3 times a day. Intravenous acyclovir is recommended for immunocompromised persons. The total duration of treatment is from 7 to 10 days.
Herpes Zoster Ophthalmicus
Herpes zoster is a common diagnosis in the emergency department (ED). Caused by the reactivation of the varicellazoster virus (VZV), zoster usually presents as a painful dermatomal rash. In addition to skin or mucosal involvement, VZV reactivation commonly affects the ophthalmic division of the trigeminal nerve and subsequently the eye. This manifestation is termed herpes zoster ophthalmicus (HZO). HZO is considered an ophthalmologic emergency, as sequelae often include severe chronic pain and vision loss.
Herpes Zoster Ophthalmicus Clinical Practice Guideline
Oral antivirals preferably within 72 hours of rash onset, or within 7 days if still has active vesicles or in debilitated/immunocompromised patient. Greatly reduces risk of ocular complications and may reduce risk of PHN
MKSAP: 64-year-old man with a new right-sided headache
Herpes zoster ophthalmicus (which includes any involvement of the structures of the eye) is an ophthalmologic emergency, as it is potentially sight threatening. A particularly high-risk lesion is when zoster involves the tip of the nose, as this is the nasociliary branch of the trigeminal nerve and thus also innervates the cornea.
Tips for Managing Herpes Zoster Ophthalmicus
Up to half of cases manifest corneal complications.
For Your Eyes Only
The diagnosis of HZO is typically made clinically from history and physical exam. Diagnostic testing is not indicated unless there are complications with the course of disease or atypical symptoms leading to clinical uncertainty. Treatment consists of oral acyclovir or alternate antivirals which have been shown to decrease the adverse outcomes related to HZO, particularly if started in the first 72 hours of initial onset of symptoms.
The College of Optometrists
Lesion at the side of the tip of the nose (Hutchinson’s sign) indicates three times the usual risk of ocular complications, but these may also occur in one in three patients without the sign.
WikEM
Antiviral therapy indicated for rash <1wk duration. Acyclovir IV 10mg/kg q8hrs x7-10 days OR Famciclovir 500mg PO q8hrs x14 days OR Valacyclovir 1g PO q8hrs.
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