The management of
herpes zoster (HZ) usually involves a multidisciplinary approach aiming to reduce complications and morbidity. Patients with
herpes zoster ophthalmicus (HZO) are referred to ophthalmologists for prevention or treatment of its potential complications. Without prompt detection and treatment, HZO can lead to substantial visual disability. In our practice, we usually evaluate patients with HZO for corneal complications such as epithelial, stromal, and disciform
keratitis;
anterior uveitis; necrotizing
retinitis; and
cranial nerve palsies in relation to the eye. These are acute and usually sight-threatening. We recommend oral
acyclovir in conjunction with topical 3%
acyclovir ointment,
lubricants, and
steroids for conjunctival, corneal, and uveal
inflammation associated with HZO. Persistent
vasculitis and
neuritis may result in chronic ocular complications, the most important of which are neurotrophic
keratitis, mucus plaque
keratitis, and
lipid degeneration of
corneal scars. Postherpetic complications, especially
postherpetic neuralgia (PHN), are observed in well over half of patients with HZO. The severe, debilitating,
chronic pain of PHN is treated locally with cold compresses and
lidocaine cream (5%). These patients also receive systemic treatment with
NSAIDs, and our medical colleagues cooperate in managing their depression and excruciating
pain.
Pain is the predominant symptom in all phases of HZ disease, being reported by up to 90% of patients. Ocular surgery for HZO-related complications is performed only after adequately stabilizing pre-existing ocular
inflammation, raised intraocular pressure,
dry eye, neurotrophic
keratitis, and
lagophthalmos.
Cranial nerve palsies are common and most often involve the facial nerve, although
palsy of the oculomotor, trochlear, and abducens nerves may occur in isolation or (rarely) simultaneously. In our setting, complete
ophthalmoplegia is seen more often than isolated
palsies, but recovery is usually complete.
Vasculitis within the orbital apex (orbital apex syndrome) or brainstem dysfunction is postulated to be the cause of
cranial nerve palsies. A
vaccine of a lyophilized preparation of the oka strain of live, attenuated varicella-zoster virus is suggested for patients who are at risk of developing HZ and has been shown to boost immunity against HZ virus in older patients.