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Herpes zoster ophthalmicus
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Herpes zoster ophthalmicus



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  • Corneal edema: Cornea has a ground-glass appearance. Associated with increast intraocular pressure (acute angle-closure glaucoma). Hyphema: Blood in the anterior chamber, usually precipitated by blunt trauma. Cataract: Sudden changes in blood glucose or electrolytes can alter hydration of the lens.
  • Patient fixes on object 15 feet away. Light held in front of one eye for 3-5 seconds, moved across to other eye for 3-5 second, then back to 1st eye. Normal response: constriction, followed by variable amounts of redilation. Eponym: Marcus Gunn pupil (named after 19th century Scottish ophthalmologist)
  • If greater than 2/3 of the nasal iris is in shadow, the chamber is probably shallow and the angle narrow.
  • Old Schiøtz tonometers: Patient supine, cornea anesthetized. Device indents cornea. Conversion made to IOC in mmHg. Electronic tonometers: Expensive and require daily calibration.
  • Associated with myopia Complaints of flashing lights, floaters, then visual loss
  • Associated with diseases that alter blood viscosity (polycythemia, sickle-cell, leukemia)
  • A subtype of optic neuritis. Inflammation of the optic disc (papilla). Optic neuritis can be associated with multiple sclerosis. Differential diagnosis of retrobulbar optic neuritis also includes compressive optic neuropathy (get a brain MRI).
  • Vascular supply to optic nerve interrupted (Giant cell arteritis, Trauma)


  • 2. CaseA 35 year old man presented with Fever - 4days Burning sensation on forehead and around left eye - 2 days Vesicular eruptions - 1 day Discharge (LE) - 1 day DV (LE) - 1 day
  • 3. History Low grade fever 4 days back associated with headache, tiredness and malaise. Pain and Burning sensation on left side of forehead and around left eye. 1 day back eruption of groups of vesicles on left side of forehead, left upper eyelid and nose associated with itching and pain. Redness and mucopurulent discharge from left eye along with decreased vision.
  • 4. Past History No long term illness, decreased appetite or weight loss. No drug history or known drug allergies. H/O chicken pox at the age of 10yrs.
  • 5. Family and Social History Unmarried, lives with parents and two siblings; all healthy. No addictions. Works in garment factory. Belongs to middle class family.
  • 6. Medical Exam Well oriented young man, in pain and concerned about his condition. Vitals: Blood pressure 120/70mmhg, pulse 80/min,temp 98 degree. CV: regular without murmur or gallop. Chest: clear. Abdomen: no significant finding.
  • 7. Ocular Exam Visual Acuity 6/6 RE 6/12 LE External Inspection :erythamatous skin, groups of flesh colored vesicles on left side of forehead, left upper eyelid, along lid margin, side and tip of the nose. (Hutchinsons Sign) Bilateral Ocular Motility normal Pupillary reactions normal
  • 8. Slit Lamp Examination RIGHT EYE LEFT EYEConjunctiva Normal HyperemiaCornea Clear Ulcer (Dendritic in Sensation pattern normal Fluorescine +ve) Sensation reducedAnterior Normal NormalchamberLens Clear ClearFundus Normal Normal
  • 9. Differential DiagnosisOCULAR SKINHerpes simplex keratitis Drug allergyHerpes zoster ophthalmicus Contact dermatitis Insect bite
  • 10. DiagnosisHERPES ZOSTER OPHTHALMICUS History Vesicles (Hutchinson’s Sign) Dendritic ulcer
  • 11. Varicella zoster virus Double stranded DNA virus Alphaherpesvirinae
  • 12. Overview VARICELLA ZOSTER VIRUSChicken pox dorsal root ganglia reactivation shingles single dermatome
  • 13. Risk Factors 90% susceptible after primary infection Old age Immunosupression Malignancy Severe illness
  • 14. Herpes Zoster Ophthalmicus Involvement of first Division (Ophthalmic) of Trigeminal nerve
  • 15. Symptoms Prodromal (fever ,fatigue ,malaise, headache) Burning pain (forehead ,eyelid ,nose) Vesicles Red Eye Watering/Discharge Photophobia Decreased vision
  • 16. Signs (Ex.Ocular) Hutchinson’s Sign( vesicles on forehead, upper eyelid, side & tip of nose)
  • 17. Hutchinsons sign
  • 18. Signs (ocular) Conjunctivitis(Hyperemia, discharge)
  • 19. Signs (ocular) Keratitis Dendritic corneal ulcer ( Fine branching pattern)
  • 20. Dendritic ulcer
  • 21. Signs (ocular) Staining Fluorescein Rose Bengal
  • 22. Signs (ocular) Corneal epithelial defects and ulcers
  • 23. Signs (ocular) Anterior Uveitis (affects a third of patients) Red eye Cells, flare Posterior synachiae Keratic precipetates (KPs) Posterior Synachiae
  • 24. Anterior Uveitis KPs
  • 25. Signs (ocular) Episcleritis Scleritis Stromal keratitis Disciform keratitis
  • 26. Complications Post herpetic neuralgia : pain that remains for more than 1 month after rash has healed 75% cases (esp. over 70yrs) aggravated by minor stimuli (touch ,heat) Cranial nerve palsies Third (most common) Fourth & sixth Optic neuritis Encephlitis Rare Cranial arteritis Guillain-Barre syndrome
  • 27. Ocular complications Eyelid scarring Raised IOP (steroid induced) Neurotrophic keratitis Chronic scleritis Lipid degeneration (cornea)
  • 28. TreatmentSystemic :Within 72hrsAcyclovir 800mg 5 times dailyFamciclovir 500mg TID
  • 29. TreatmentLocal: Acyclovir skin ointment (rash) Topical Acyclovir Topical antibiotics (Chloramphenicol) Topical steroids (uveitis)
  • 30. Treatment of ComplicationsPost herpetic neuralgia Cold compress Local CAPSAICIN oint (QID) / LIDOCAINE oint Pain killers Oral Tricyclic antidepressantsNo Post herpetic neuralgia
  • 31. Message A common and treatable viral infection. Patient education/Counseling. Post herpetic neuralgia is extremely painful condition. Can transmit chicken pox.