Herpes ophthalmicus, also known as ophthalmic shingles, is a viral infection caused by the reactivation of the varicella-zoster virus (VZV). This virus, causing chickenpox, remains dormant in nerve tissue. When VZV reactivates in the ophthalmic branch of the trigeminal nerve, it primarily affects one eye and the surrounding facial area. Prompt attention is required due to its vision impact.
Causes and Symptoms
VZV reactivation often happens later in life, particularly in individuals over 50 or those with a weakened immune system. Once reactivated, the virus travels along nerve pathways to the skin and eye, causing inflammation and symptoms.
Prodromal symptoms may precede the rash by several days. These include pain, tingling, or a burning sensation on one side of the forehead or scalp. A characteristic rash then appears: small, painful, red blisters or vesicles. This rash typically covers the forehead and sometimes extends to the eyelid on one side of the face.
A lesion on the tip of the nose, known as Hutchinson’s sign, indicates potential eye involvement. This suggests the nasociliary nerve, a branch of the ophthalmic nerve, is affected. Eye symptoms include pain, redness, and light sensitivity (photophobia). Eyelid swelling and blurry vision are also common, indicating the virus’s ocular impact.
Diagnosis and Medical Evaluation
Diagnosis typically begins with clinical evaluation of the distinctive rash distribution. A healthcare provider observes the characteristic blistering rash on the forehead, eyelid, and potentially the tip of the nose, noting it usually appears on one side of the face and does not cross the midline.
A comprehensive eye examination determines the extent of eye involvement. An ophthalmologist uses a slit lamp, a specialized microscope, for detailed inspection of the eye’s anterior structures (cornea, iris, lens).
Fluorescein eye stain detects corneal issues during the eye exam. This dye stains damaged corneal areas, making abrasions or ulcers visible under blue light. If the rash is atypical or diagnosis unclear, a blister fluid sample may be collected for laboratory analysis, such as PCR studies, to confirm VZV presence.
Treatment Approaches
Prompt treatment for herpes ophthalmicus reduces symptom severity and minimizes long-term complications. Primary treatment involves high-dose oral antivirals. These drugs (acyclovir, valacyclovir, famciclovir) inhibit VZV replication, slowing its spread.
Antiviral therapy ideally begins within 72 hours of rash appearance for best outcome. Beyond antivirals, adjunctive treatments manage symptoms and inflammation. Steroid eye drops control inflammation inside the eye, particularly if uveitis or keratitis develop. These drops reduce swelling and pain.
Pain management is important, as rash and nerve pain can be significant. Over-the-counter or prescription pain relievers are recommended. In some cases, pupil-dilating eye drops (e.g., cyclopentolate, atropine) reduce pain and prevent certain types of glaucoma.
Potential Complications
Herpes ophthalmicus can lead to long-term issues if not managed effectively. One common complication is postherpetic neuralgia (PHN), persistent nerve pain lingering for months or years after the rash heals. This pain can be debilitating.
Beyond PHN, serious ocular complications can arise, potentially affecting vision permanently. These include corneal scarring, obscuring vision. Chronic inflammation inside the eye (uveitis) can lead to discomfort and damage.
Increased eye pressure (glaucoma) can also develop, potentially damaging the optic nerve and causing irreversible vision loss. Other complications include corneal numbness, increasing eye susceptibility to injury, and in rare cases, blindness. These outcomes underscore the importance of timely medical evaluation and adherence to prescribed treatment.