Treatment Plan

Managing Herpes Zoster Ophthalmicus, Part 1


treatment plan


Managing Herpes Zoster
Ophthalmicus, Part 1

comfort and blurring as well. Her physician diagnosed herpes zoster and prescribed Valtrex q8h and Darvocet-N q6h. Christi complained of nausea and vomiting that began shortly after her initial dose of narcotic analgesic.


Signs and Symptoms

Her presenting visual acuities were 20/25 OU. Gross external examination revealed a diffuse maculopapular rash on the left side of her face and grade 3+ swelling of the upper lid and periorbital skin (Figure 1). The left conjunctiva showed grade 3+ injection in all quadrants, and follicles were apparent on the tarsal conjunctiva.

Examination of the cornea revealed multiple, slightly elevated, dendrite-shaped lesions that stained both with fluorescein and lissamine green. The anterior chamber was free of flare or cells. We diagnosed varicella zoster (shingles) and herpes zoster ophthalmicus (HZO). We prescribed topical Voltaren (Novartis Pharmaceuticals) drops q4h, and Systane (Alcon) every hour.

The following day, Christi reported little improvement in her symptoms. Slit lamp signs were unchanged except for reduced injection OS. Applanation tensions were OD 13 mmHg OS 10 mmHg.


Changing Tactics

We instructed Christi to discontinue the Darvocet and begin ibuprofen 400mg q4h. We also added Pred Forte (Allergan) every

hour. The next day she reported better ocular comfort and no vomiting. We gave her a tapering schedule for the steroid.

Four days later, Christi's skin lesions had begun to crust, and there was remarkably less lid edema. The areas of dendritic corneal staining were almost resolved, and no injection remain-ed. Tensions were unchanged.


About VZV

Varicella zoster virus (VZV), a

member of the herpes virus family, is a highly contagious agent that causes chicken pox in children and shingles in adults. Approximately 90 percent of the general population is sero-positive for VZV. Shingles is 15 times

more common in individuals over 50 years old and in HIV patients. It occurs most commonly in the spring. The virus may remain latent for decades, but reactivates when a decrease in cell-mediated immunity occurs.

Varicella zoster is characterized by fever, malaise and a maculo-vesicular rash. Patients fre-
quently report hyperesthesia, paresthesias and pruritus. These lesions follow dermatomes and are invariably unilateral. The thoracic and lumbar dermatomes prevail in incidence.

Ocular complications occur in approximately 50 percent of all patients who have involvement of the trigeminal nerve. HZO is potentially the most devastating of all manifestations of varicella zoster, ranging in severity from an uncomplicated but uncomfortable conjunctivitis to sight-threatening uveitis, glaucoma and disciform keratitis. CLS


hristi is a 37-year-old female whose primary care provider referred her to our office. Three days earlier, she developed unilateral facial pain and a rash above her left eye. She noted ocular discomfort

Figure 1. Facial rash and ocular swelling from varicella zoster.

Dr. Townsend is in private practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center. E-mail him at