A 28-year-old male presented with pain, redness and rashes on the left side of his face diagnosed with herpes zoster ophthalmicus (HZO). Examination found vesicopapular rash and decreased vision in the left eye. He was prescribed antiviral medications to treat the acute infection and prevent complications. HZO reactivates latent varicella zoster virus causing dermatomal distribution of rash. It can cause ocular inflammation and long term neuralgia requiring multimodal treatment.

2. • Name- Vineet Raj,
• Age- 28 years, Male
• Resident- Indore
• Visited eye OPD on 12th Feb 2018.
• He was referred from dermatology dept as a
diagnosed case of HZO, for ophthalmology
opinion.

3. • Chief Complaints:
pain, redness and
rashes on left side
of fore head,
temple, lids, face
and side of the nose.

4. History:
The rash and pain appeared over
left side of the face one day
before.
On examination:
• VA: RE 6/6, LE 6/9
• Vesicopapular rash on left side of
forehead, temple, left upper
eyelid, lower lid, along lid margin,
ala of the nose.
• Bilateral Ocular Motility normal
• Pupillary reactions normal

5. RIGHT EYE LEFT EYE
• Conjunctiva- Normal
• Cornea- Clear,
Sensation normal
• Anterior chamber-
Normal
• Pupil-RRR
• Iris-NCP
• Lens-Clear
• Fundus-Normal
• Conjunctiva-Hyperemia,
mucoid discharge +nt
• Cornea-Clear, Sensation
normal
• Anterior chamber-
Normal
• Pupil-RRR
• Iris-NCP
• Lens-Clear
• Fundus-Normal

6. Treatment Prescribed
• Tab Valciclovir 1gm TDS*7 days
• Tab PCM 500mg BD*7 days
• Oint Calamine for local application
• Eye oint aciclovir 3% 5 times in LE*7 days
• Eye drop CMC 0.5% QID LE
• Tab Amitrptylin 75 mg OD
• Adv to take precautions as the patient might
be infectious to family members.

7. Herpes Zoster Virus
• Core of linear ds DNA
genome,
• Icosahedral protein
capsid,
• Protein tegument,
• Envelope of viral
glycoproteins.

8. • The production of
viral progeny
destroys the
infected cell.
• HSV types 1 and 2
and VZV establish
latent infections in
dorsal root ganglia
such as the
trigeminal ganglion.

9. • Primary VZV infection occurs upon direct contact
with VZV skin lesions or respiratory secretions via
airborne droplets.
• VZV latency occurs in neural ganglia. (T3-L3,CN V)
• reactivates in approximately 20% of infected
individuals.
• Of all cases with zoster, 15% involve the ophthalmic
division of CN V
• Zoster (shingles) represents endogenous reactivation
of latent virus in people with a waxing level of
immunity to infection.

10. • VARICELLA ZOSTER VIRUS
• Chicken pox ─› dorsal root ganglia ─› reactivation
─› shingles

11. • Age- sixth to ninth decades
• Majority patients are healthy, with no specific
predisposing factors.
• More common in patients on
▫ immunosuppressive therapy
▫ systemic malignancy
▫ a debilitating disease, or HIV infection
▫ after major surgery
▫ trauma
▫ radiation

12. CLINICAL PRESENTATION
• Fever, malaise, warmth,
redness, increased
sensation in the
affected dermatome.
• The rash of begin as
macules―› papules
―›vesicles ―› pustules

13. • dermatitis may
result in large
scabs that resolve
slowly and leave
significant scarring

14. • Inflammation of almost any ocular tissue can
occur and recur in HZO.
• Eyelid-
▫ vesicular eruption,
▫ secondary bacterial infection,
▫ eyelid scarring,
▫ marginal notching,
▫ loss of cilia,
▫ trichiasis,
▫ cicatricial entropion or ectropion.
▫ Scarring and occlusion of the lacrimal puncta
• Conjunctiva-
▫ Follicular conjunctivitis

15. • Sclera-
▫ Episcleritis,
▫ Scleritis
• Cornea-
▫ punctate and dendritic keratitis
▫ Decreased corneal sensation
▫ Nummular corneal infiltrates
▫ Interstitial keratitis
▫ Disciform keratitis
▫ Corneal vascularisation
▫ Lipid keratopathy
▫ Corneal opacity

16. • Ant Chamber-
trabeculitis, Raised IOP
• Iris- Iritis
• Choroid-Focal
choroiditis.
• Retina-occlusive retinal
vasculitis, RD

17. • Optic Nerve- Papillitis, Retrobulbar Neuritis
• Orbit- Eyelid ptosis, orbital oedema, proptosis,
• Cranial Nerve- CN III most commonly involved

18. Structure Acute Chronic
• Eyelid Rash and vesicles Scarring, loss of lashes
• Conjunctiva Conjunctivitis
• Cornea Corneal ulcers scarring, loss of sensation
• Uvea Uveitis iris damage, glaucoma
• Retina Retinitis CME
• Optic nerve Optic neuritis Glaucoma
• Orbit Partial or complete paralysis of eye movements

19. Diagnosis
• Usually clinical
• Typical presentation involving one dermatome.
• Involvement of more than one dermatome
shows severe immunosuppresion

20. • Laboratory Inv
▫ viral culture,
▫ PCR.
▫ Serologic testing
• D/d
▫ Herpes simplex
▫ Drug reaction
▫ Contact dermatitis
▫ Insect bite

21. HSV VZV
• Dermatomal distribution incomplete complete
• Pain moderate severe
• Skin scarring no common
• PHN no common
• Iris atophy patchy sectoral
• B/L involvement uncommon no
• Recurrent epithelial common rare
keratitis
• Corneal hypoesthesis sectoral/diffuse may be severe
• Dendrite central ulceration, no central ulcer,
morphology terminal bulbs dendritiform
mucous plaque

22. Management
• Oral anti viral agents-
▫ famciclovir 500 mg 3 times per day,
▫ valacyclovir 1 g 3 times per day,
▫ acyclovir 800 mg 5 times per day
• reduces viral shedding from vesicular skin
lesions
• reduces the chance of systemic dissemination
of the virus,
• decreases the incidence and severity of the
most common ocular complications.

23. • may reduce the duration if not the incidence of
postherpetic neuralgia if begun within 72 hours of
the onset of symptoms.
• Intravenous acyclovir therapy is indicated in patients
at risk for disseminated zoster due to
immunosuppression. It is supported by iv fluids and
bed rest.
• Vaccination against varicella is recommended for
anyone older than 12 months of age without a history
of chickenpox or with a negative serology.

24. • Prednisone
▫ 30 mg orally twice daily on days 1 - 7;
▫ then 15 mg twice daily on days 8 - 14;
▫ then 7.5 mg twice daily on days 15 – 21
• This will reduce severity of the acute signs
and symptoms but not the incidence or
severity of PHN.

25. • Corneal ulcers require topical anti viral and
tear substitutes.
• Stromal involvement require lubrication or
topical corticosteroids.
• If HZO results in decreased corneal
sensation, then surgery may be required to
protect this surface by tarsorrhaphy.

26. • HZO uveitis- corticosteroid and cycloplegic
eye drops.
• Severe inflammation unresponsive to eye
drops resulting in optic nerve inflammation or
eye movement problems may require
corticosteroid pills.
• If Glaucoma develops, then additional eye
drops or even surgery may be required to
control the pressure.

27. • Lotions containing calamine (e.g., Caladryl)
may be used on open lesions to reduce pain
and pruritus.
• Topically administered lidocaine (Xylocaine)
and nerve blocks have also been reported to
be effective in reducing pain.

28. Post herpetic neuralgia
• Neuralgic pain persists for more than a month
beyond healing and lasts for more than six
months.
• Insect crawling or burning sensation in
trigeminal dermatome.
• Pain can be severe enough to result in sleep
disturbance, anorexia and depression.

29. • Elderly individuals, immuno-compromised are
more likely to be affected.
• Pathology involves ischemic vasculitis of the
nerves resulting in fibrotic scar involving
large fibers.
• Cold compressions are advised.

30. Tricyclic antidepressants
• Amitriptyline
▫ 10 to 25 mg PO HS
▫ Increase dosage by 25 mg every 2 to 4 weeks
until response is adequate, or to maximum
dosage of 150 mg per day.

31. • Nortriptyline
▫ 10 to 25 mg PO HS;
▫ increase dosage by 25 mg every 2 to 4 weeks
until response is adequate, or to maximum
dosage of 125 mg per day.
• Imipramine
▫ 25 mg PO HS;
▫ increase dosage by 25 mg every 2 to 4 weeks
until response is adequate, or to maximum
dosage of 150 mg per day.

32. Anticonvulsants
• Carbamazepine (Tegretol)
▫ 100 mg PO HS;
▫ increase dosage by 100 mg every 3 days until
dosage is 200 mg three times daily, response is
adequate or blood drug level is 6 to12 μg per mL
(25.4 to 50.8 μmol per L).
• Gabapentin (Neurontin)
▫ 100 to 300 mg PO HS;
▫ increase dosage by 100 to 300 mg every 3 days
until dosage is 300 to 900 mg three times daily
or response is adequate.

33. • Capsaicin 0.025 percent skin cream depletes
substance P.
• Its a tachykinin that transmits pain impulse
and prevents reaccumulation.

34. Prognosis
• Most patients with HZO have a single attack and
do not go on to get further attacks.
• Visual outcome is generally good, with vision loss
usually due to corneal problems rather than
uveitis.
• Some patients, however, may develop chronic
disease, including uveitis that requires long-term
therapy and may persist for years.

35. Message
• A common and treatable viral infection.
• Patient education/counseling.
• Post herpetic neuralgia is extremely painful
condition.
• Can transmit chicken pox.