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A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Herpes zoster ophthalmicus in patients at risk for the acquired immune deficiency syndrome (AIDS). Natural history of herpes zoster ophthalmicus: predictors of postherpetic neuralgia and ocular involvement. Varicella zoster virus retrobulbar optic neuritis preceding retinitis in patients with acquired immune deficiency syndrome. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults.
Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. It is not known what triggers herpes to zoster, but the incidence increases according to the age. The diagnosis is based on the distribution of vesicles throughout the passage of the nerve in a flank of the face and in its treatment the use of aciclovir is recommended to avoid complications.
The ill person must ingest balanced foods and nutritious, to rest but that can and if the dream is interrupted during the night, she must make several siestas in the day.
IMPORTANT the content of this note is informative and it does not replace the medical diagnosis, reason why we do not become people in charge on its use. A 64-year-old Chinese man presented to the ED with five days of increasingly blurry vision in his right eye.
Ophthalmologic exam was significant for slight right-sided conjunctival irritation with no exudates or obvious corneal scarring.
In the United States, VZV primary infection rate reaches nearly 100% by 60 years of age; however, this rate will likely decrease with the widespread usage of the VZV vaccine. Classically, HZO begins with flu-like symptoms including fever, myalgia, and malaise for approximately one week. Physical exam should include a thorough ophthalmologic exam including external inspection, visual acuity, visual fields, extra ocular movements, pupillary response, funduscopy, intraocular pressure, anterior chamber slit lamp exam, and corneal exam with and without staining. Diagnostic testing is rarely indicated, as diagnosis can almost always be made by a combination of history and physical. In the ED treatment consists of local wound care, pain control, initiation of antiviral medication, and antibiotics if needed. Oral opiate and nonsteroidal anti-inflammatory medications are frequently indicated for pain and may be augmented by the use of cycloplegics in patients who display features of iritis.
In otherwise healthy individuals with minimal eye involvement, most sources suggest outpatient treatment with seven to 10 days of oral acyclovir at a dose of 800mg five times and famciclovir) offer equivalent benefits and have reduced frequency of dosing, which may improve patient compliance. HZO is a potentially serious reactivation of VZV in the distribution of the ophthalmic division of the trigeminal nerve. An old lady takes a grandchild, out of concern and compassion, to a traditional healer for advice and prevention of cataract, a condition the child is likely to develop sixty years later. It is partly the increased, multifactorial, infant and young child morbidity and mortality that led to the United Nations Convention on the Rights of the Child. The challenge lies in a better understanding of the immense eye problems affecting the under-served and vulnerable paediatric group in developing countries and in devising comprehensive national programmes to deal with these problems. Improved media reporting in recent years has exposed some of the neglect and abuse children are subject to in many societies.
In developing countries, poverty, social and cultural beliefs and taboos and exposure to traditional practices predispose the vulnerable paediatric group to abuse. The authors wish to highlight a group of children who, due to well-meant but harmful traditional practices in combination with neglect and sometimes outright abuse, present with ophthalmic manifestations. The most common eye diseases treated in children are allergies, conjunctivitis and trachoma.
In some communities, already with depleted food supplies, it is customary for adults and children to share a meal around a common plate. A nine-day old child of an overburdened and overworked mother, living in a small crowded place, was left by the mother near a kerosine cooking pot. Many mothers and children, through no fault of their own, are forced to live in over-crowded, unhealthy environments and under marginalised conditions that greatly contribute to trachoma, the second leading cause of blindness in Africa. Sexual abuse of children, aged 10-15 years, in low-income countries may be more widespread than is generally thought. A husband is often the only person in a household who gives consent or decides if a child can receive hospital treatment, be it surgical or medical, emergency or otherwise. Very rarely have the eye health planners concentrated their strategies on conditions 0ike squint with resultant amblyopia, refractive errors and dyslexia. Children with such eye problems are scorned and even expelled from school for no fault of their own – by teachers who do not understand the experience and the disability of these children. We feel that clear and definite steps should be taken in some developing countries to establish an awareness about the Rights of the Children and to protect them from the negative effects of cultural, traditional and social practices.
The education system is the developing world?s broadest channel for the dissemination of health information, health attitudes and practices. Greater emphasis must be given to the issue of integrating the traditional healers into primary eye care systems.
It is a member of the same family (Herpesviridae) as herpes simplex virus, Epstein-Barr virus, and cytomegalovirus.
Because the nasociliary branch innervates the globe, the most serious ocular involvement develops if this branch is affected. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Later in life, the virus may reactivate, causing a characteristic rash of small blisters, frequently on the chest or forehead, which form crusts and may leave scars. Although this disease often occurs in normal, healthy people, it occurs more frequently in elderly or immune-compromised individuals. An ophthalmologist looks for elevated pressure in the eye, inflammation inside the eye, and herpes zoster lesions on the surface of the eye.
Caused by the reactivation of the varicellazoster virus (VZV), zoster usually presents as a painful dermatomal rash. The blurring was associated with mild photophobia and a right-sided headache which he described as a burning pain over his forehead.
HENT exam showed no obvious rashes or lesions; however, the patient had mild hyperesthesia over his right forehead. The patient had normal lids and consensual pupillary reflexes with mild discomfort on ipsilateral and contralateral pupillary testing. Ophthalmology was consulted, and the patient was discharged to ophthalmology clinic, where the ED findings were confirmed. The lifetime risk of varicella zoster is between 10–20% in patients who have had chicken pox.


By definition HZO is reactivation of VZV in the ophthalmic division of the trigeminal nerve (V1), and accounts for 10–25% of all herpes zoster cases.1 While HZO does not necessarily affect the structures of the eye, many of the acute and long-term complications associated with the disease are the result of direct viral toxicity to the eye or the ensuing inflammatory response within the eye.
Typically, patients then develop a painful unilateral dermatomal rash in the distribution of one or more branches of V1: supraorbital, lacrimal, and nasocilliary.
As in our patient, the differential diagnosis includes a broad range of pathology: herpes simplex keratitis, other viral or bacterial conjunctivitis, uveitis, glaucoma, trauma, chemical exposure, vascular occlusion, migraine, cluster headache, trigeminal neuritis, optic neuritis, vasculitis, and others. It is possible to use a Tzanck smear or Wright stain to determine whether lesions contain herpes-type virus (though these will not differentiate between VZV and other herpes viruses). Acyclovir and other similar antivirals have been shown to significantly decrease adverse outcomes related to HZO if started within 72 hours of initial symptoms.5,6,7,8 Studies report reduced pain during the outbreak, reduced likelihood of postherpetic neuralgia, increased rate of skin healing, decreased duration of viral shedding, and decreased incidence of corneal involvement. Usually this entity presents with classic findings that make diagnosis simple; however, as was the case with our patient, HZO may easily be confused with more common and benign eye pathology.
A ?concoction? of various herbs is prepared and prescribed which subsequently leads to bilateral total damage of the corneae, a disruptive ?keratomalacia-like? reaction. Yet, they are conspiculously neglected when national eye health and rehabilitation programmes are planned. It is estimated that childhood blindness causes 90 million blind years (number blind x length of life).
There is generally a high incidence of eye diseases in children which means that children are particularly at risk of harmful traditional and cultural therapeutic practices. A herbal twig implanted under the eyelid in a child with mild allergic conjunctivitis led to fulminating panophthalmitis (Figure 1). In the case of trachoma, one healer in Kenya used the rough leaf of .ordia sinesis to rub on the tarsal conjunctiva until it bled. Inadequate nutrition and poor hygiene due to lack of water cause varying degrees of malnutrition and diseases that lead to blindness. A case presented here exemplifies the plight of these children due to man-made disasters and catastrophes (Figure 3).
In rare instances, such abuse may lead to traumatic eye conditions with serious long-term psychological and physical consequences for the child.
We would like to document a 14 months old child with frank gonococcal conjunctivitis (Figure 5) contracted from an infected mother. These condition can lead to major visual impairment, mostly unnoticed by parents and teachers. Teachers and leaders can play a major role in promoting the health of children and protecting one of our most essential organs – the eyes. These first-line providers of health are easily accessible and acceptable to the rural populations and can make a vital contribution at community level in rural areas.
Unless otherwise stated, all content is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Most patients with herpes zoster ophthalmicus present with a periorbital vesicular rash distributed according to the affected dermatome. Reactivation of the latent virus in neurosensory ganglia produces the characteristic manifestations of herpes zoster, commonly known as shingles. Classically, involvement of the tip of the nose (Hutchinson's sign) has been thought to be a clinical predictor of ocular involvement.
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In addition to skin or mucosal involvement, VZV reactivation commonly affects the ophthalmic division of the trigeminal nerve and subsequently the eye.
The patient did not wear corrective lenses and denied trauma, chemical exposure, discharge, foreign body sensation, sick contacts, or history of similar problems. In clinic the patient was started on topical steroids in addition to antivirals and cycloplegics, and was discharged home with early follow up by ophthalmology. After the initial infection, VZV remains latent in the dorsal root ganglia of sensory neurons, possibly reappearing as herpes zoster later in the patient’s life. It is thought that approximately 50% of those diagnosed with HZO will develop complications. The skin manifestations usually begin as an erythematous macular rash, progressing over several days into papules, vesicles, and then pustules.
If the classic rash is present, a brief exam will limit this differential; however, as in our patient, this would not be adequate to diagnose a patient presenting with purely ocular involvement.
Viral culture, direct immunoflourescence assay, or PCR may also be used to confirm the diagnosis. It is not proven that the patient accrues these benefits if the medications are started after the 72-hour window, but given the extremely low side-effect profile of the drugs and the serious sequelae of complications, most physicians recommend administering antivirals during the first seven to 10 days of symptoms. Admission is recommended for those with known immunodeficiency, patients on immunosuppressive medications, involvement of multiple dermatomes (which may indicate immunosuppression), retinal involvement, corneal ulceration, or serious bacterial superinfection. A helpless child, victim of traditional and social practices, enters into a life of almost 50 blind and hopeless years. It states that all countries shall ensure good health for children and protect them from neglect and all forms of exploitation. In high-income countries, it is recognised that factors such as broken families, social dysfunction, depression and unemployment play a major role, for instance, in child battering (physical assault of children). Herbal ocular ?medicines? are responsible for an estimated 8-10% of corneal blindness in Africa. Another chewed the leaves of boscia coreacea, and the juice obtained along with the saliva was applied to the conjunctival sac, a procedure causing irritation, pain and possibly chemical burns. A number of these cases are accidents in the home such as burns, falls with injury, or even suffocation. Advanced cases of infected perforations or inoperable retinoblastoma (Figure 7) pose a challenge to the attending ophthalmologist. A minority of patients may also develop conjunctivitis, keratitis, uveitis, and ocular cranial-nerve palsies.
Normal aging, poor nutrition, and immunocompromised status correlate with outbreaks of herpes zoster, and certain factors such as physical or emotional stress and fatigue may precipitate an episode.Herpes zoster ophthalmicus occurs when reactivation of the latent virus in the trigeminal ganglia involves the ophthalmic division of the nerve. Treatment includes topical capsaicin cream, over-the-counter analgesics, tricyclic antidepressants, and anticonvulsants.18Cranial nerve palsies involving the third (most common), fourth, and sixth nerves may occur rarely (Figure 5).
Review of systems was positive for approximately one week of malaise, myalgia, and subjective fevers. Many of these poor outcomes can be prevented or ameliorated with early recognition, treatment, and referral. These eventually rupture and scab, and in immunocompetent individuals will resolve over the course of two to three weeks. All patients with the possible diagnosis of HZO require ophthalmologic consultation prior to discharge from the ED in order to ensure full evaluation for more serious complications.
Once the diagnosis of HZO is entertained, appropriate antiviral and adjunctive therapy should be initiated and ophthalmology consultation should be requested for evaluation and treatment of common complications.


This permanent damage is the result of herbs with a very high pH or the introduction of micro-organisms that can lead to suppurative keratitis and endophthalmitis. Also observed were cases of gonococcal conjunctivitis among children and these followed instillation by the traditional healer of his own infected urine into the eyes of children presenting with trivial ocular complaints.
This may result from experimentation with traditional medicines and later the father may refuse to give his consent for surgical treatment. Permanent sequelae of ophthalmic zoster infection may include chronic ocular inflammation, loss of vision, and debilitating pain. Today, new oral antiviral medications are providing shingles patients with a quicker, more complete recovery.
HZO is considered an ophthalmologic emergency, as sequelae often include severe chronic pain and vision loss.
The patient denied sore throat, rhinorrhea, hearing changes, rashes, or any other concerns. In about 60% of cases patients will complain of a painful dermatomal prodrome prior to the development of any rash. This pattern of infection occurs in approximately 65% of patients with HZO;4 however, other eye findings are more frequent and range from simple conjunctivitis to retinal necrosis and detachment. Extract of lemon peels are used for serious eye infections, whereas juice from tomato leaves is used for milder conditions. Parents desperately wanting a male child, deliberately pushed this teenage daughter into a fire (Figure 8). Antiviral medications such as acyclovir, valacyclovir, and famciclovir remain the mainstay of therapy and are most effective in preventing ocular involvement when begun within 72 hours after the onset of the rash. Direct ocular involvement is not specifically correlated with age, gender, or severity of disease. Optic neuritis has been noted in about one in 400 cases and may precede retinal disease or follow acute herpes zoster ophthalmicus infection (Figure 6).17,19,20The rightsholder did not grant rights to reproduce this item in electronic media.
Oral acyclovir may be beneficial as an adjunct to topical antivirals and topical steroids in severe cases of zoster keratouveitis. In order to ensure proper follow up and to minimize morbidity, the accurate and timely diagnosis of HZO in the ED is extremely important. The patient did not know if he had ever had chicken pox or cold sores, and he denied any past medical problems, surgeries, allergies, or medications. Fundoscopic exam revealed normal appearing eye grounds with no evidence of hemorrhage, vascular occlusion, papilledema, or retinal detachment. Timely diagnosis and management of herpes zoster ophthalmicus, with referral to an ophthalmologist when ophthalmic involvement is present, are critical in limiting visual morbidity.
While typically an easy diagnosis to make based on history and skin findings, occasionally HZO presents as an isolated ophthalmologic process that is difficult to distinguish from other more benign causes of a red eye.
Patients may develop blepharitis and present with ptosis secondary to edema and inflammation. A vast majority of patients will have vesicular lesions on the eyelids that resolve with minimal scarring.Conjunctivitis is one of the most common complications of herpes zoster ophthalmicus. The conjunctiva appears injected and edematous, often with petechial hemorrhages.9 The findings usually resolve within one week.
The clinical features of corneal disease include direct viral infection, antigen-antibody reactions, delayed cell-mediated hypersensitivity reactions, and neurotrophic damage.7 Patients with corneal disease present with varying degrees of decreased vision, pain, and light sensitivity. Corneal complications occur in approximately 65 percent of cases of herpes zoster ophthalmicus.7Epithelial Keratitis. The earliest corneal finding is punctate epithelial keratitis.10 On slit lamp examination, this appears as multiple, focal, swollen lesions that stain with rose bengal or fluorescein dye.
These lesions probably contain live virus and may either resolve or progress to dendrite formation. Punctate epithelial keratitis may present as early as one or two days after the initial skin rash, while dendrites often present at four to six days but can appear many weeks later.11Herpes zoster virus dendrites appear as elevated plaques and consist of swollen epithelial cells. Dendrites also stain with rose bengal and fluorescein dye ( Figure 2, part b) and can be viewed by Wood's lamp or slit lamp examination. The earliest finding of corneal stromal involvement presents during the second week of disease, occurring in 25 to 30 percent of patients with herpes zoster ophthalmicus.13 The condition, known as anterior stromal keratitis or nummular keratitis, is characterized by multiple fine granular infiltrates in the anterior corneal stroma below the epithelial layer (Figure 3). Most of the infiltrates lie directly beneath pre-existing dendrites or areas of punctate epithelial keratitis. This later stage of stromal keratitis is relatively uncommon and typically develops three to four months after the initial acute episode, but development can range from one month to many years later.7 It is usually central and preceded by anterior stromal keratitis.
The keratitis may present as a lesion consisting of a localized area of inflammation affecting all levels of the stroma, or as peripheral infiltrates that may have a surrounding immune ring.
Corneal edema may be a prominent feature at this stage, usually with associated anterior chamber inflammation.
A chronic relapsing course is not unusual, especially without timely and adequate treatment. Corneal neovascularization and lipid infiltrates may occur in patients with uncontrolled chronic disease. The pathogenesis of stromal disease probably involves a delayed cell-mediated hypersensitivity reaction.Neurotrophic Keratopathy.
Neurotrophic keratitis is the end result of decreased corneal sensation from herpes zoster virus-mediated destruction, including susceptibility to mechanical trauma, decreased lacrimation, and delayed epithelial healing.7 Corneal thinning is a serious complication that may lead to corneal perforation. Using preservative-free lubricating drops and ointment can prevent the development of epithelial defects.UVEITISAnterior uveitis, which is diagnosed by slit lamp examination, refers to inflammation of the iris and ciliary body and occurs frequently with herpes zoster ophthalmicus.
The inflammation is generally mild and transient, but it frequently causes a mild elevation in intraocular pressure. As with stromal keratitis, the course of disease may be prolonged, especially without timely, adequate treatment. Chronic inflammation can lead to endothelial cell injury, resulting in corneal edema.EPISCLERITIS AND SCLERITISFindings of episcleritis include localized or diffuse redness, as well as pain and swelling of the conjunctiva and episclera.
Both conditions may be accompanied by localized stromal keratitis.ACUTE RETINAL NECROSIS AND PROGRESSIVE OUTER RETINAL NECROSIS SYNDROMESHerpes zoster virus is considered the offending agent in most cases of acute retinal necrosis and progressive outer retinal necrosis syndromes. Acute retinal necrosis is characterized by peripheral patches of retinal necrosis that rapidly coalesce (Figure 4), occlusive vasculitis, and vitreous inflammation. Conversely, immunocompromised patients with progressive outer retinal necrosis are unable to mount a vitreous inflammatory response, leading to rapid involvement of the macula.



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