MBBS SAQ · Infectious Diseases / Dermatology / Ophthalmology
Ophthalmic herpes zoster — recognition, complications and management
A final-prof / NEET-PG SAQ on ophthalmic herpes zoster — recognising V1 distribution and the Hutchinson sign, urgent ophthalmology referral, systemic antiviral (valaciclovir/IV aciclovir), ocular complications (keratitis, uveitis, acute retinal necrosis), and the stepwise neuropathic pain ladder for postherpetic neuralgia.
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Question
A 72-year-old man with type 2 diabetes presents with 4 days of severe right-sided forehead pain, followed by a vesicular rash over the right forehead, upper eyelid and the tip of his nose. He complains of redness and blurred vision in the right eye. Outline your diagnosis, the critical bedside assessment, complications, and immediate and definitive management.
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Diagnosis: ophthalmic herpes zoster (V1) with ocular involvement. The unilateral, painful, vesicular rash in the ophthalmic division of the trigeminal nerve (forehead, upper eyelid) plus the vesicle on the tip of the nose (Hutchinson sign — nasociliary nerve) and visual symptoms establish ophthalmic zoster with ocular disease — an ophthalmology emergency.[1]
Critical bedside assessment.
- Confirm the dermatomal, unilateral distribution (V1, not crossing the midline).
- Hutchinson sign — vesicle on tip/side of nose → nasociliary nerve → cornea at risk.
- Focused eye examination: visual acuity (each eye), fluorescein staining under cobalt-blue light for dendritic/punctate keratitis, slit-lamp for anterior chamber inflammation (uveitis, keratic precipitates), intraocular pressure (secondary glaucoma), red reflex/fundus (acute retinal necrosis, optic neuritis).
- Assess immune status and systemic involvement (diabetes, immunosuppression) and exclude disseminated/multidermatomal disease.
- Vitals and (if systemic upset) respiratory assessment for varicella-zoster dissemination.
Complications of ophthalmic zoster.[1]
- Anterior segment: punctate/dendritic/disciform/neurotrophic keratitis, episcleritis/scleritis, anterior uveitis, secondary glaucoma.
- Posterior segment / nerve: optic neuritis, acute retinal necrosis (vision-threatening).
- Postherpetic neuralgia (risk high — age 72, ophthalmic site).
- VZV vasculopathy — contralateral stroke weeks–months later.
Immediate management.
- Urgent ophthalmology referral (same day) — for slit-lamp, definitive ocular treatment.
- Systemic antiviral — given ocular involvement and age over 50: IV aciclovir 10 mg/kg every 8 hours (renal-adjusted, well hydrated) for 7–10 days; or oral valaciclovir 1 g three times daily for 7–10 days if ophthalmology confirms no sight-threatening disease. Do not delay starting.
- Analgesia for the acute neuritis — paracetamol ± NSAIDs (in an adult), weak opioid; add an early neuropathic agent (amitriptyline 10–25 mg nocte, or gabapentin/pregabalin) given the high PHN risk.
- Eye protection/lubrication (preservative-free lubricant, taping the eye at night if lid closure impaired).
- Isolation: contact precautions with lesions covered.
Definitive / stepwise management.[1][4]
- Topical corticosteroids (for uveitis) ONLY under ophthalmology supervision — contraindicated in active epithelial (dendritic) keratitis.
- Topical antivirals are not routinely used in immunocompetent ophthalmic zoster (systemic therapy is effective).
- Postherpetic neuralgia prevention/prophylaxis: antiviral within 72 h (already done), aggressive acute pain control; consider a short course of oral prednisolone (modest benefit on acute pain and quality of life, but does NOT prevent PHN) — weigh against diabetes.
- PHN management (likely needed given age): neuropathic pain ladder — TCA (amitriptyline/nortriptyline) or gabapentinoid (gabapentin/pregabalin); topical lidocaine 5% patches and topical capsaicin 8% for localised PHN; tramadol / strong opioid / specialist pain clinic for refractory pain.
- Diabetes: optimise glycaemic control; review corticosteroid choice.
- Vaccination on recovery: recombinant zoster vaccine (Shingrix) for future prevention (over 90% efficacy) once the acute episode has resolved.
Common errors
- Not recognising ophthalmic zoster / Hutchinson sign — missing ocular involvement and not referring to ophthalmology → preventable corneal blindness.
- Delaying antivirals beyond 72 h in a high-risk (over 50, ophthalmic) patient who should be treated regardless of the window.
- Prescribing topical corticosteroid to the eye without ophthalmology review — sight-threatening in active dendritic keratitis.
- Under-treating PHN — not starting a neuropathic agent early, leaving the elderly patient with disabling pain.
- Forgetting corticosteroid caution in diabetes and not counselling about VZV vasculopathy/stroke risk after ophthalmic zoster.
Examiner notes
- The exam wants the structured approach: recognise V1 distribution and the Hutchinson sign → urgent ophthalmology → systemic antiviral (IV if ocular involvement) → ocular-complication awareness (keratitis, uveitis, ARN) → neuropathic pain ladder for PHN.
- State that topical steroids are for uveitis only and under ophthalmology — a classic trap.
- A strong candidate mentions recombinant zoster vaccine for prevention and VZV vasculopathy/stroke as a delayed complication of ophthalmic zoster.[1][4]
References2ShowHide
- [1]Patil A, Goldust M, Wollina U. Herpes zoster: A Review of Clinical Manifestations and Management. Viruses, 2022.PMID 35215786
- [4]Johnson RW, Dworkin RH Treatment of herpes zoster and postherpetic neuralgia. BMJ, 2003.PMID 12676845