This is zoster of the 1st (ophthalmic) branch of the trigeminal nerve and accounts for 20% of all shingles. Only thoracic nerves are more affected (55%). Pain, tingling or numbness around the eye may precede a blistering rash which is accompanied by much inflammation. In 50% of those with HZO the globe is affected (corneal signs iritis in >40%-rarely sectoral iris atrophy). Nose-tip involvement-Hutchison's sign-means involvement of the nasociliary branch of the trigeminal nerve which also supplies the globe and makes it likely that the eye will be affected. The eye can be afflicted with little rash elsewhere. Beware dissemination if immunocompromised. Varicella zoster virus (VZV) may persist in the cornea and retina. The different patterns of retinal disease caused by VZV relate to immune status.
Presentation:
- Mucopurulent conjunctivitis
- Limbal lesions
- Preauricular node tenderness
- Episcleritis
- Visual loss
- V nerve palsy
- Keratitis
- Iritis (atrophy)
- Pupillary distortion
- Optic atrophy
- Scleritis
Treatment
Systemic antivirals improve the early quality of life but cannot be relied on to prevent post-herpetic neuralgia.1 Famciclovir offers the best dosing schedule (750mg once daily PO for 7d; SE vomiting; headache) but is much more expensive than aciclovir (800mg 5 times daily PO for 7 days-it has more serious SE such as hepatitis and renal failure). Start within 4 days of onset. It is wise for all with ophthalmic shingles to see a specialist if the nose-tip is involved or the eye turns red within 3 days to exclude anterior uveitis with a slit lamp. Prolonged steroid eyedrops may be needed.
Wassilew S 2005 J Eur Acad Dermatol Venereol 19 47. Incidence of neuralgia is 16% if aged >65yrs (also risk→ if rash is extensive). It causes insomnia, fatigue, depression, interference with daily living-even suicide. Amitriptyline 25mg at night may help, as may gabapentin (max 3.6g/day, but see BNF).
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