Slit Lamp Photo: Herpes Zoster Ophthalmicus
Title: Slit Lamp Photo: Herpes Zoster Ophthalmicus
Author (s): Michael Murri, 4th Year Medical Student, Baylor College of Medicine
Keywords/Main Subjects: Herpes Zoster Ophthalmicus; Pseudodendrite; Varicella Zoster
Diagnosis: Herpes Zoster Ophthalmicus
Description of Image:
Varicella zoster virus (VZV) is a double-stranded DNA virus of the herpes family that initially causes a characteristic skin rash and flu-like symptoms known as varicella or “chickenpox.” After initial resolution, varicella zoster may lie dormant in nerve cells for decades. Herpes Zoster, also known as shingles, is caused by the reactivation of VZV, which results in painful blistering lesions and nerve pain in a characteristic dermatomal distribution. Herpes Zoster Ophthalmicus (HZO) is a reactivation of latent VZV in the ophthalmic (V1) distribution of the trigeminal nerve, which has serious implications when involving the orbit.1
A patient with HZO may present with malaise and neuralgia several days before eruption of painful vesicles, with involvement of the tip of the nose (Hutchinson’s sign) indicating involvement of the nasociliary nerve and increased risk of ocular involvement.2 Corneal involvement may include epithelial erosions, cell and flare in the anterior chamber and the appearance of pseudodendrites on the corneal surface. As opposed to dendrites associated with HSV, pseudodendrites do not have terminal end bulbs, have weaker fluorescein staining, and present more of an elevation with a “stuck on” appearance as opposed to an ulceration in HSV. Distinguishing HSV from VZV by physical findings can be important as the dosage of antiviral treatment must be elevated for VZV. Maximal treatment benefit is seen when the correct dose is initiated within 72 hours of presentation.3 Definitive diagnosis can be achieved through viral culture. Treatment often consists of oral and topical antivirals as well as pain management. There is a lack of evidence that corticosteroids aid in outcomes.4 In some patients, prophylactic treatment must be continued indefinitely in order to prevent recurrence.
This image is a fluorescein stained corneal of a 71 year old white male with a history of recurrent HZO. On exam, he was found to have resolving skin lesions in the ophthalmic V1 distribution as well as this corneal epithelial elevation, which on staining was identified as a pseudodendrite without terminal end bulbs. Because of the patient’s history of recurrent HZO, he was treated with 800 mg of oral acyclovir five times daily and ganciclovir ophthalmic gel four times a day.
1) Cohen EJ. Management and Prevention of Herpes Zoster Ocular Disease. Cornea. 2015; 34. doi:10.1097/ico.0000000000000503.
2) Anderson E, Fantus RJ, Haddadin RI. Diagnosis and management of herpes zoster ophthalmicus. Disease-a-Month. 2017; 63(2):38-44. doi:10.1016/j.disamonth.2016.09.004.
3) Mcdonald EM, Kock JD, Ram FS. Antivirals for management of herpes zoster including ophthalmicus: a systematic review of high-quality randomized controlled trials. Antiviral Therapy. 2011; 17(2):255-264. doi:10.3851/imp2011.
4) He L, Zhang D, Zhou M, Zhu C. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database of Systematic Reviews. 2008. doi:10.1002/14651858.cd005582.pub2.
Faculty Approval by: Amy Lin, MD; Griffin Jardine, MD