Photoclinic: Herpes Zoster Ophthalmicus

An otherwise healthy 40-year-old woman presented with a rash on her forehead and nose and erythema of her right eye. The rash had appeared 2 days earlier and was asymptomatic. Based on the clinical findings, Sunita Puri, MD, of Decatur, Ala, diagnosed herpes zoster ophthalmicus. Herpetic involvement of the ophthalmic branch, or first division, of the trigeminal (fifth) cranial nerve accounts for nearly 10% of all herpes zoster cases. The lesions on the tip of the nose (Hutchinson sign) are an important clinical and prognostic sign. They indicate nasociliary nerve and, possibly, eye involvement.  Ocular complications affect about 50% of patients who have herpes zoster ophthalmicus. Typically, the conjunctiva is red and swollen and keratitis develops. Rarely, uveitis may develop and lead to secondary glaucoma. In severe cases, there may be loss of vision. Other ocular complications include neuroparalytic keratopathy, Adie pupil caused by ciliary ganglion damage, ophthalmoplegia, and optic nerve involvement. Antiviral therapy that is started within 72 hours of the appearance of the lesions can reduce ocular complications, and early administration of an oral corticosteroid may prevent postherpetic neuralgia. Timely referral to an ophthalmologist is recommended.