Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Abstract

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Keywords: Herpes zoster; Herpes zoster ophthalmicus; Herpes zoster vaccination; Ocular complications; Prevention; Primary care; Treatment.

Fig. 1

Search strategy

Fig. 2

Incidence rates of herpes zoster ophthalmicus in the USA (1994–2018) by age [16]

Fig. 3

Progression over time and complications of herpes zoster ophthalmicus [29, 41, 48, 53, 54, 56, 59, 82]. IOP intraocular pressure, HZO herpes zoster ophthalmicus

Fig. 4

Treatment algorithm for collaborative care between primary care provider and ophthalmologist [2, 48, 53, 77, 118, 119]. ^aInvolvement of the skin supplied by the nasociliary nerve. ^bIdeally ≤ 72 h after onset of rash, but beyond 7 days if new lesions are present in patients with complications, such as herpes zoster ophthalmicus, or at risk of complications, such as immunocompromised patients. ^cTopical ophthalmic corticosteroids should not be used in the absence of antiviral agents