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Herpes zoster ophthalmicus
- Unilateral painful vesicular skin lesions in the innervation zone of the 1st trigeminal branch (V1)
due to reactivation of Varicella zoster viruses - Cave: Hutchinson’s sign (tip of nose affected) -> sign of intraocular involvement
- Medical history: duration of skin lesions, onset of symptoms -> relevant for treatment decision
- Diagnosis: Clinical diagnosis, swab of skin lesions not mandatory if findings are clear
Herpes zoster Keratitis
- Findings:
- acute epithelial keratitis = keratitis dentritiformis
- nummular keratitis
- about 10 days after onset of rash
- Interstitial keratitis (= stromal keratitis)
- in approx. 5% of patients; about 3 weeks after onset of rash
Herpes zoster Uveitis anterior
- see Uveitis anterior
- Keratouveitis: Uveitis anterior + keratitis
- Findings: fine granulomatous endothelial precipitates, anterior chamber cells/flare, sectorial iris atrophy, increased eye pressure (due to iridocyclitis)
Other findings in herpes zoster
- Conjunctivitis (papillary and/or follicular): frequent
- Episcleritis: usually resolves spontaneously
- Scleritis: rare; oral steroid therapy may be indicated
- Acute retinal necrosis -> always dilate the pupils to examine the retina
- Neurotrophic keratitis -> see neurotrophic keratopathy
- CN III, IV, VI palsy
Therapy
Herpes zoster Keratitis
- Virgan gel (Gangciclovir) 5x/d (alternative Zovirax (aciclocir) ointment 5x/d) until lesions are healed or 3 days longer (not mandatory if treated systemically) for epithelial keratitis
- Valtrex (Valacivlovir) 1g 3x/d for 7 to 10 days (consider treating longer until lesions are healed)
- Start therapy within 72 hours after onset of disease if possible, but only within 5-7 days after onset
- Additional local steroids for nummular or interstitial keratitis
- e.g. Dexafree UD gtt (Dexamethasone) 4-5x/d, taper over 4-6 weeks
Zoster ophthalmicus (without eye involvement)
- Valtrex 1g 3x/d for 7-10 days (to reduce risk of ocular involvement and post-herpetic neuralgia)
- patients with zoster ophthalmicus should be regularly checked for ~6 weeks for ocular involvement (e.g. anterior uveitis, often asymptomatic)
- topical therapy for skin lesions
- e.g. Tanno Hermal Lotio several times a day
- alternatively, if not superinfected (only crusted): Aqua Dalibouri solution (copper zinc solution), apply gauzes with solution 1x 15min per day
- alternatively if superinfected: Fucicort cream 1-2x/day (Fusidic Acid/Betamethasone)
Zoster ophthalmicus with anterior uveitis
- Valtrex 1g 3x/d for 7-10 days, then continue with reduced dose (e.g. 3x500mg)
- Pred Forte AT initially hourly (or less depending on anterior chamber cells / flare) +/- Ultracortenol ointment (Prednisolone) at night; taper slowly if response is good
- See anterior uveitis
- Scopolamine gtt 2x/d in case of severe inflammation (to prevent posterior synechiae)
Neuropathic pain
- Lyrica (Pregabalin) 50mg p.o.
- Dosing regimen: e.g. 1st day: 1-0-0, 2nd day: 1-0-1, 3rd day: 1-1-1, 4th day: 2-1-1, 5th day: 2-1-2, from 6th day: 2-2-2
- if pain does not improve under 300 mg daily: admit to neurology
Acute retinal necrosis (ARN)
Prophylaxis
- Evaluate long-term prophylaxis from 2 relapses/year, consider Valtrex 250mg 2x/d, high risk patients 2x500mg/d.
- Vaccination (Shingrix): according to BAG 2 recommended for
- immunocompetent patients between 65 – 79
- immunocompromised patients over 50 years
- in severe immunodeficiency from 18 years
Sources
- EyeWiki Herpes Zoster Ophthalmicus
- AWMF Leitlinie – Diagnostik und Therapie des Zoster und der Postzosterneuralgie
- The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease; Nika Bagheri MD, Brynn Wajda MD, et al; Lippincott Williams&Wilkins; 7th Edition (2016)
- Kanski’s Clinical Ophthalmology: A Systematic Approach; Jack J. Kanski MD, Brad Bowling MD; Saunders Ltd.; 8th Auflage (2015)
- 1 von Eyerounds.org, © The University of Iowa; Licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
- 1 Contributor: Jeff Welder, MD Jesse Vislisel, MD; Photographer: Cindy Montague, CRA
- 2 BAG-Bulletin 47 vom 22. November 2021: Neue Empfehlungen zur Impfung gegen Herpes zoster: Impfstoff Shingrix®