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Herpes Zoster Ophthalmicus: A Review for the Internist

Patient with herpes zoster ophthalmicus demonstrating Hutchinson sign.

Patient with herpes zoster ophthalmicus demonstrating Hutchinson sign.

Herpes zoster ophthalmicus occurs due to reactivation of the varicella zoster virus in the ophthalmic branch of the fifth cranial nerve. This disease primarily affects the elderly as well as the immunocompromised and can result in a wide range of ophthalmic morbidity. Systemic antiviral therapy is the mainstay of treatment; however, consultation with an ophthalmologist is typically indicated. Herein we present a review of this common entity including epidemiology, pathophysiology, evaluation, treatment, follow-up, and an update on the current body of literature.

Varicella is caused by primary infection from human herpesvirus type 3. Following primary infection, which often occurs in childhood, the virus remains dormant in neurosensory ganglia. It may be reactivated, typically years or decades later, resulting in the cutaneous disease commonly known as shingles or herpes zoster. According to the Centers for Disease Control and Prevention (CDC), there are an estimated 1 million cases of herpes zoster annually in the US,12 and nearly 1 in 3 people will develop shingles during their lifetime.3 Herpes zoster classically results in a unilateral neurocutaneous reaction in the dermatome served by a particular neurosensory nucleus, causing pain and a pustular rash; serious complications such as superinfection, long-term pain, and ophthalmic involvement can result in significant morbidity. Up to 4% of patients presenting with herpes zoster require hospitalization to aid in management of complications.3

Herpes zoster ophthalmicus represents 10% to 20% of herpes zoster cases.13 Herpes zoster ophthalmicus occurs when human herpesvirus type 3 reactivation presents in the first division of the trigeminal nerve, also known as the ophthalmic division. Reactivation may manifest with pain and a periocular cutaneous rash limited to the periorbital region; however, 50% to 72% of patients demonstrate involvement of the eye itself.1456 Such involvement ranges from a cutaneous reaction limited to the eyelids to corneal ulceration or retinal disease resulting in permanent loss of vision. Careful evaluation and treatment of patients with herpes zoster ophthalmicus is imperative to decrease long-term morbidity. This review is intended to provide useful clinical information about the epidemiology, pathophysiology, clinical manifestations, and treatment of this common disease entity, as well as an update on new developments and future directions of treatment.


A recent study utilizing a database with access to the medical records of over 4 million patients in the US revealed a total of 9152 incident cases of herpes zoster in a 12-month period. This translates to an overall age- and sex-adjusted incidence of 3.2 cases per 1000 person-years. The sex distribution was approximately 59.9% female and 40.1% male. The peak incidence was between the ages of 50 and 79 years, with a skew toward older individuals, with the highest rates observed among patients over age 80 years (10.9 cases per 1000 person-years).7

The incidence of herpes zoster ophthalmicus, in particular, has not been the subject of a nationwide study; however, both the Miami Veterans Administration Healthcare System and Kaiser Permanente in Hawaii have evaluated their rates of herpes zoster ophthalmicus.78 The Miami study collected data over a span of 4 years, revealing 90 patients with herpes zoster ophthalmicus. The majority (97%) were immunocompetent, and the frequency of herpes zoster ophthalmicus with eye involvement was 0.05%.7 The Kaiser study documented 134 cases in 1 year in a population of 217,061 patients. This is an overall incidence of 30.9 per 100,000 person-years.8 These studies are retrospective and likely underestimate the incidence of this common entity.

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-Ivan Vrcek, MD, Eileen Choudhury, MD, Vikram Durairaj, MD

This article originally appeared in the January 2017 issue of The American Journal of Medicine.

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