What is ophthalmic shingles?

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June 27, 2024

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What is ophthalmic shingles?

Ophthalmic shingles, also known as herpes zoster ophthalmicus (HZO), is a form of shingles that affects the eye and surrounding areas. It occurs when the varicella-zoster virus (the same virus that causes chickenpox and shingles) reactivates in the ophthalmic branch of the trigeminal nerve. This condition can lead to severe pain, eye inflammation, and potentially serious complications that can affect vision. Here is a detailed overview of ophthalmic shingles:

Causes

Varicella-Zoster Virus (VZV):

  • Primary Infection: Initially causes chickenpox. After the chickenpox resolves, the virus remains dormant in the nerve cells.
  • Reactivation: The virus can reactivate later in life, particularly when the immune system is weakened, causing shingles. When reactivation occurs in the ophthalmic branch of the trigeminal nerve, it results in ophthalmic shingles.

Symptoms

Early Symptoms:

  • Prodromal Phase: Before the rash appears, there may be nonspecific symptoms such as headache, fever, malaise, and a burning or tingling sensation on the forehead or around the eye.

Rash and Blisters:

  • Appearance: Painful, blistering rash that typically appears on one side of the face, forehead, and possibly the tip of the nose (Hutchinson’s sign, which indicates a higher risk of eye involvement).
  • Progression: The blisters eventually burst, crust over, and heal over a few weeks.

Ocular Symptoms:

  • Eye Pain: Severe pain in or around the eye.
  • Redness: Redness of the eye and surrounding area.
  • Swelling: Swelling of the eyelids.
  • Tearing: Increased tearing or watery eyes.
  • Photophobia: Sensitivity to light.
  • Blurry Vision: Possible blurred vision due to inflammation.

Complications

1. Keratitis:

  • Description: Inflammation of the cornea.
  • Symptoms: Pain, redness, blurred vision, sensitivity to light.
  • Complications: Can lead to corneal ulcers and scarring, resulting in vision impairment.

2. Uveitis:

  • Description: Inflammation of the uvea (middle layer of the eye).
  • Symptoms: Eye pain, redness, blurred vision, sensitivity to light.
  • Complications: Can cause severe eye pain and vision problems.

3. Glaucoma:

  • Description: Increased intraocular pressure due to inflammation.
  • Symptoms: Eye pain, blurred vision, halos around lights.
  • Complications: Can lead to optic nerve damage and vision loss.

4. Scleritis:

  • Description: Inflammation of the sclera (the white part of the eye).
  • Symptoms: Severe pain, redness, and sometimes vision loss.
  • Complications: Can lead to significant eye damage if untreated.

5. Retinal Necrosis:

  • Description: Severe inflammation and damage to the retina.
  • Symptoms: Decreased vision, floaters, flashes of light.
  • Complications: Can cause retinal detachment and permanent vision loss.

6. Optic Neuritis:

  • Description: Inflammation of the optic nerve.
  • Symptoms: Vision loss, pain with eye movement.
  • Complications: Can result in temporary or permanent vision loss.

Diagnosis

Clinical Evaluation:

  • Medical History: Detailed history of symptoms, including the onset and progression of the rash and eye symptoms.
  • Physical Examination: Examination of the skin lesions and distribution of the rash.

Ophthalmic Examination:

  • Visual Acuity Test: Measures the clarity of vision.
  • Slit-Lamp Examination: Allows detailed examination of the anterior structures of the eye.
  • Fundus Examination: Evaluates the retina and optic nerve.
  • Intraocular Pressure Measurement: Checks for increased eye pressure associated with glaucoma.

Treatment

Antiviral Medications:

  • Examples: Acyclovir, Valacyclovir, Famciclovir.
  • Purpose: Early administration (within 72 hours of rash onset) can reduce the severity and duration of symptoms and prevent complications.
  • Dosage: Follow the prescribed dosage and duration as directed by a healthcare provider.

Corticosteroids:

  • Purpose: To reduce inflammation and prevent complications such as uveitis and keratitis.
  • Forms: May be administered as oral tablets, eye drops, or injections, depending on the severity and location of inflammation.

Pain Management:

  • Over-the-Counter Pain Relievers: Acetaminophen or NSAIDs such as ibuprofen.
  • Prescription Medications: Stronger pain medications may be necessary for severe pain.

Topical Treatments:

  • Antibiotic Eye Drops or Ointments: To prevent secondary bacterial infections.
  • Cycloplegic Eye Drops: To relieve pain associated with uveitis by relaxing the ciliary muscle.

Prevention

Vaccination:

  • Shingles Vaccine (Shingrix): Recommended for adults aged 50 and older, and for those with weakened immune systems. The vaccine significantly reduces the risk of developing shingles and its complications.

Prognosis and Long-Term Management

Regular Follow-Up:

  • Eye Exams: Regular follow-up appointments with an ophthalmologist are crucial to monitor the condition and manage any complications.
  • Managing PHN: If postherpetic neuralgia (PHN) develops, long-term pain management strategies may be needed.

Conclusion

Ophthalmic shingles (herpes zoster ophthalmicus) is a serious condition that can lead to significant eye complications, including vision loss. Early diagnosis and prompt treatment with antiviral medications and corticosteroids are essential to reduce the severity of symptoms and prevent long-term damage. Regular monitoring by an ophthalmologist is crucial for managing complications and ensuring the best possible outcomes. Vaccination with the shingles vaccine is highly recommended to prevent shingles and its associated complications. If you experience symptoms of shingles near or involving the eyes, seek immediate medical attention to prevent serious outcomes.

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