Herpes Zoster Ophthalmius is a condition when the varicella-zoster virus, or childhood chickenpox virus, reactivates in the Trigeminal nerve, specifically the V1 dermatome which contains the eye. Typically, the virus manifests in an initial painful eruption of vesicles on the forehead, the side of the nose, upper eyelid and eye. Herpes Zoster can reactivated in adult years and is commonly known as shingles

Incidence

Per the CDC, there are one million new cases of zoster each year in the United States. Unfortunately between 25 percent and 40 percent of all cases have ophthalmic complications. In most cases, herpes zoster ophthalmicus is mild, and usually results in short-term inflammation, such as a temporary keratitis, which usually resolves without topical antiviral treatment.

However, a minority of patients can go on to develop recurrent iritis, and are at risk for secondary glaucoma, cataracts, corneal scarring or retinitis that can be sight-threatening. Nerve damage can also result in a neurotrophic cornea, in which the lack of sensation can lead to future ulcers, scarring or thinning.  This often requires aggressive medical or surgical intervention to prevent permanent corneal damage

Another problematic aspect of zoster is the development of chronic and persistent pain, called postherpetic neuralgia (PHN). The pain of PHN can be severe and disabling, and can so affect patients’ quality of life

Treatment

If caught within 72 hours of the onset of the rash, shingles is treated with a 7-10 day course of antiviral pills. Sometimes steroid drops are used if there is significant corneal or intraocular inflammation. Once started, steroids often need to be decreased very slowly, frequently over months or years.

Prevention

 The best treatment for shingles or zoster is the shingles vaccine.  We encourage all of our patients who are candidates to have this vaccine before this disease develops.  Everyone above age 50 should discuss the vaccine with their primary medical doctor to determine eligibility.

The older vaccination called the Zostavax was no longer available starting July 1, 2020 due to lower effectiveness compared to the newer vaccine, called Shingrix.

In the United States, the low rate of vaccination is a public health problem. According to 2015 CDC data, only 31% of eligible people 60 years of age
and older had received a herpes zoster vaccine.

Shingrix Vaccine for Shingles

Shingrix is a vaccine injection approved by the FDA in October 2017 for patients 50 years and older.

  • In the studies done on Shingrix, there was more than a 90% decrease in the occurrence of shingles in all age groups of those who were vaccinated.
  • All immunocompetent Americanas should be vaccinated with Shingrix even if they were previously immunized with another vaccine because Shingrix has been shown to be much more effective in preventing shingles.
  • Requires 2 doses, administered 8 weeks apart
  • Cost: $280. This may not always be completely covered by insurance, however, the benefit of the vaccine far outweighs the cost.

Find more information on the Center for Disease Control website:  https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

Pro Tip 1: Our patients tell us that after the vaccine, you can feel run down for a day or two as your body builds the necessary immunity

Pro Tip 2: Patients with a history of herpes zoster ophthalmicus (HZO) with ocular involvement should be examined by their ophthalmologist within several weeks before and after vaccination as the vaccine has been reported to spur a flair or ocular inflammation in some patients.

Pro Tip 3: The optimal timing of vaccine after an episode of herpes zoster is not specified by the CDC. However, it is thought that an episode of herpes
zoster stimulates cell-mediated immunity for a period of time, perhaps a year or so, and vaccination is not urgent. Vaccination should be delayed after active Zoster eye disease is well controlled.