B02.39 Herpes Zoster Dermatitis Of Eyelid

The herpes zoster virus in its primary form causes varicella or chickenpox.  After the primary infection, the virus remains in the dorsal root or other sensory ganglion and may lay dormant for years or decades.  

Aging, immunosuppressive illness, new stress, or medical treatment can cause a reactivation of the latent varicelal-zoster virus.  Reactivation is characterized by a localized skin rash erupting in a single dermatome called herpes zoster or shingles.

Structural Damage to the Eye and Adnexa

• Vesicular skin rash on the eyelids can lead to scarring
• Corneal scarring can result from infiltrates, stromal edema, or neovascularization
• Corneal ulcers can cause the cornea to become necrotic
• Chronic inflammation secondary to the viral infection can result in structural damage to the cornea

Functional Damage to the Eye

• Profound vision loss due to corneal scarring
• Profound vision loss secondary to corneal necrosis

To obtain the information required to determine a clinical diagnosis of herpes zoster ophthalmicus and to prescribe a treatment plan, the following service components of a medical eye examinaion should be performed. 

• Patient history
• General medical observation
• External examination
• Adnexal examination
• External ocular examination with biomicroscopy
• Ophthalmoscopy
• Intraocular pressures

Patient History

Patients with herpes zoster ophthalmicus may present with any of the following abnormal clinical signs and symptoms.

• Vesicular skin rash respecting the midline
• Varying degree of pain
• Redness (usually unilateral)
• Foreign body sensation
• Tearing
• Itchy eyes
• Swelling of the eyelids
• Blurred vision
• Fever
• Malaise

External Examination

A face-to-face inspection of the external ocular and facial areas.

Clinical Appearance of the Skin Acute skin rash is characterized by active vesicles on an erythematous base respecting the midline

Adnexal Examination

• Preauricular lymphadenopathy may be present

External Ocular Examination with Biomicroscopy

Clinical Appearance of the Cornea Pseudodentrites may stain mildly with fluorescein Stromal keratitis stromal edema Corneal ulceration Corneal scarring Anterior chamber reaction Elevation in intraocular pressure secondary to uveitis

Ophthalmoscopy

The ophthalmoscopic examination may reveal some of the clinical signs of herpes zoster opthalmicus – especially in patients that are immunocompromised.

Clinical Appearance of the Retina

• Optic Neuritis
• Optic Papillitis

Clinical Appearance of the Retina

• Posterior pole reaction indicating retinitis
• Posterior pole reaction indicating choroiditis

No specific classification is in place for herpes zoster ophthalmicus.

The key to treating herpes zoster ophthalmicus is making an early diagnosis while administering systemic, topical and ophthalmic pharmacologic agents as indicated by the severity of the condition.

Early diagnosis is within 72 hours of viral reactivation (e.g., acute skin rash with active lesions present).

Systemic Pharmacologic Treatment for Skin Involvement

• Acyclovir 800 mg orally 5x / day for 7-10 days; or, 
• Famcyclovir 500 mg orally 3x / day for 7-10 days; or, 
• Valcyclovir 1000 mg orally 3x / day for 7-10 days

Topical Pharmacologic Treatment for Skin Involvement

• Bacitracin or erythromycin ointment applied to the skin lesions 2x / day for 7-10 days

Supportive Treatment for Skin Involvement

• Warm compress to the periocular skin to keep the area clean 3x / day for 7-10 days

Topical and Systemic Pharmacologic Treatment for Ocular Involvement

• Non-preservative artificial tears can be used in mild forms of herpes zoster ophthalmicus to lubricate the ocular surface
• Prophylactic antibiotic ointment/drops for secondary infections
• Topical steroids to control corneal pseudodendrites, superficial punctate keratitis, neurotrophic keratitis or anterior chamber reactions.
• Topical cycloplegic agent for moderate anterior chamber reactions
• Pain may be severe in the initial two weeks.  Analgesics may be recommended.  Monitor for post herpetic neuralgia which can have an early onset and last for years.

1.  Potter W.  An Overview of Ocular Herpetic Disease.  May 2010. http://www.reviewofoptometry.com/continuing_education/tabviewtest/lessonid/106745/.  Last accessed January 20, 2015.
2.  Sowka J. Kabat A.  The ‘Other’ Ocular Herpes.  RevOptom.  15 July 2009. http://www.revoptom.com/content/d/therapeutic_review/i/786/c/14565/.  Last accessed August 17, 2014.