Managing Herpes Zoster Ophthalmicus in the ED: Eye on the Virus 

-Case- 

A 62-year-old man presents to the ED with severe right-sided eye pain, headache, and a rash along his forehead. He noticed tingling and burning in the area two days ago, followed by redness and fluid-filled blisters. His vision is slightly blurred, and you spot a vesicle on the tip of his nose. 

With this rash and symptoms in mind, treatment is urgent to prevent permanent vision loss; what are we worried about?

-Evaluation-

Varicella-zoster virus (VZV) reactivates from latency in the dorsal root ganglia, leading to shingles (herpes zoster). When it affects the ophthalmic division of the trigeminal nerve (V1), it becomes herpes zoster ophthalmicus (HZO), a sight-threatening condition.

Key symptoms include a unilateral dermatomal rash with vesicles on an erythematous base, classic for your VZV rash. As you can expect, this is painful, often described as a burning or tingling sensation before rash onset. One unique finding, particularly on exam questions, is the Hutchinson’s sign. Seen in our case above, this is when you note vesicles on the tip of the nose, underscoring the high risk for ocular involvement.

Concerning complications of HZO:

• Keratitis, uveitis, or retinitis → May lead to vision loss
• Postherpetic neuralgia (PHN) → Chronic neuropathic pain
• Secondary bacterial superinfection

Diagnosis:

• Clinical diagnosis (based on characteristic rash and distribution)
• Fluorescein stain + slit lamp exam → look for pseudodendrites, keratitis, or uveitis!
• Tzanck smear/PCR is confirmatory if uncertain, but very rarely used in the ED

-Management-

1. Antivirals ASAP to reduce complications! It is key to start within 72 hours of rash onset for best outcomes
2. Ophthalmology Consultation is often required in cases where ocular involvement (keratitis, uveitis) is suspected
3. Adjunctive therapy: topical steroids for inflammation, artificial tears for symptomatic relief, and pain control with NSAIDs/gabapentin for postherpetic neuralgia
4. Future prevention: the shingles vaccine (Shingrix) is key! It is recommended for adults ≥50 years to prevent recurrence

-Fast Facts-

• Hutchinson’s Sign = high risk of ocular involvement
• Start antivirals ASAP (<72 Hours) to reduce complications!
• Shingrix vaccine works to prevent future outbreaks

HZO is a sight-threatening complication of VZV reactivation that requires early recognition and treatment. While the associated rash is classic and typically fairly easy to spot, identifying it is only the beginning! When shingles involves the eye, swift action saves vision!

Want to learn more? Listen to our great podcasts and read our in-depth study guides on other emergency medicine topics!

Cheers,

Tamir Zitelny, MD

-References-

1. Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology. 2008;115(2 Suppl):S3–S12. doi:10.1016/j.ophtha.2007.10.009
2. Yawn BP, Wollan PC, Kurland MJ, et al. Herpes zoster eye complications: Rates and trends. Mayo Clin Proc. 2013;88(6):562–570. doi:10.1016/j.mayocp.2013.03.013
3. Tran KD, Falcone MM, Jiramongkolchai K, et al. Herpes zoster ophthalmicus: Diagnosis and management. Curr Opin Ophthalmol. 2022;33(6):492–500. doi:10.1097/ICU.0000000000000843
4. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44(Suppl 1):S1–S26. doi:10.1086/510206
5. Tamhankar MA, Volpe NJ, Eggenberger ER, et al. Herpes zoster ophthalmicus and ocular motor cranial neuropathies. Neurologist. 2008;14(6):389–391. doi:10.1097/NRL.0b013e31815a51be