Ophthalmic Shingles

(Also known as Herpes Zoster Ophthalmicus)

Latent Herpes Zoster can reactivate from the ophthalmic division of the trigeminal nerve causing the classic rash around the scalp, forehead and eyelids. As the ophthalmic division also supplies the cornea with sensation it can cause inflammation within the eyeball.

Signs/Symptoms

  • Redness around and in the eye
  • Swollen eyelids/ blistered eyelids
  • Photophobia
  • Hutchinson’s sign- if a herpes zoster rash involves the tip of the nose then this is known as a positive Hutchinson’s sign. It indicates nasociliary nerve involvement (also innervates the eye)
  • Reduced vision
  • Pain
  • Headache
  • Nausea

Causes

  • Varicella-zoster virus — the virus that causes chickenpox. If you have had chicken pox then the virus can lay dormant in your nerve tissue for many years.
  • Stress and or a weakened immune system can allow the varicella-zoster virus to reappear.

Treatment

  • Treatment should be started within the first few days of any rash appearing. This is why emergency referral is so important The treatment for HZO is antiviral tablets such as acyclovir, famciclovir or valacyclovir. These drugs can shorten the attack of shingles and will usually relieve the pain.
  • Bristol Eye Hospital’s Emergency Referral guidelines state: “In the first 72 hours. Aciclovir 800mg 5xday for 7 days should be commenced. There is some benefit to initiating treatment for up to seven days following the start of shingles and this can reduce disease progression and post-herpetic neuralgia.”

Red Flags

  • Speed of referral
  • History of Herpes zoster

When one or more of these red flags is raised, a conversation with another registrant in practice should take place following which appropriate referral or management should be actioned and noted. If there are no other registrants in practice then contact should be made with colleagues elsewhere or contact should be made for advice to the local Hospital Eye Service (HES).