Generality
Herpes zoster ophthalmic is an eye disease caused by the varicella-zoster virus (VZV), the same one that causes shingles and chickenpox .
The cause of this pathology is the reactivation of the infection : if it remains latent (ie "dormant") along the terminations of the cranial nerves, the varicella-zoster virus can recur, on certain occasions, also involving the eyeball .
The herpes zoster ophthalmic manifests itself with the appearance of an erythema and involves the presentation of blisters gathered in "bunches". The eruption affects a circumscribed area of the eyelids, ie that of the nerve where the virus had remained dormant. Pain is characteristic, which begins as a tingling, then becomes burning and hardly bearable. Later, the infection can spread to the conjunctiva and the cornea.
With adequate care, the symptoms of ophthalmic herpes zoster generally resolve within a few weeks. It should be noted, however, that antiviral drugs and ointments do not eliminate the virus, but contribute to making it return to a state of latency.
What's this
Ophthalmic herpes zoster is an eye infection caused by the varicella-zoster virus (VZV).
Herpez zoster: short introduction
- Shingles is a viral disease that, in the most common form, manifests as a painful rash, characterized by the presence of numerous vesicles .
- St. Anthony's fire is nothing more than a recurrence of primary infection, that is, of chickenpox . In other words, only individuals who have had chickenpox can develop shingles.
- Once chickenpox is contracted, the immune system cannot completely destroy the virus, but repels it, forcing it to hide in the cells of the nerve roots . Here, the virus remains inactive and quiet, "hiding" for years or even a lifetime.
- However, it can happen that - in correspondence with some situations that make the organism more vulnerable - the virus can reactivate itself and launch a new attack. In this case, following the path of a nerve, the varicella-zoster virus produces the typical painful eruption in the cutaneous area of distribution of the nerve itself .
If it remains latent along the terminations of the cranial nerves, the varicella-zoster virus can recur, on certain occasions, also involving the eyeball .
Causes
Ophthalmic herpes zoster is a pathology of the eye caused by the reactivation of the varicella-zoster virus (VZV, Varicella-Zoster Virus), acquired during the primary varicella infection and remained clinically latent within the spinal ganglia and sensory nerves .
This viral agent is the same that causes shingles: if it remains latent along the terminations of the cranial nerves, the varicella-zoster virus can recur, on certain occasions, also involving the eyeball. To be interested in the onset of ophthalmic herpes zoster is, in particular, the naso-ciliary nerve - as reported, sometimes, by the presence of blisters on the tip of the nose ( Hutchinson's sign ).
Note
When herpes zoster affects the ophthalmic branch of the fifth cranial nerve (trigeminus) it is possible to develop lesions on the eye, in about 50-70% of cases. In some cases, when the first vesicles appear along the distribution area of the first trigeminal branch, ocular lesions appear simultaneously.
Herpes zoster ophthalmic: why do you reactivate?
Ophthalmic herpes zoster can occur for a variety of reasons, usually associated with a generalized decrease in immune defenses .
It is not surprising, therefore, that ophthalmic herpes zoster is observed above all in elderly people: aging is associated with the progressive decline of specific cell-mediated immunity to VZV, especially if the immune system is compromised by concomitant diseases, such as neoplastic diseases and diabetes .
Herpetic lesions tend to reappear even in the presence of strong psychological and / or physical stress or as a consequence of excessive exposure to sunlight or marked hormonal alteration .
Other factors that can predispose to ophthalmic herpes zoster are the use of some immunosuppressive drugs and immunodeficiency secondary to chemotherapy, radiotherapy and HIV infection .
Although primary infection with VZV mostly affects young people, shingles and its complications mainly affect older people . According to medical statistics, one in ten people, mostly after age 50, will have shingles during their lifetime.
In some cases, herpes zoster ophthalmic may occur following contact with another person suffering from cold, ocular or, less often, genital herpes . In addition, self- contamination is possible, ie the spread of the virus can occur simply by touching the eyes with the hands after having scratched or rubbed a herpetic lesion (eg of the lips) during the contagious phase.
Symptoms and Complications
Herpes zoster ophthalmic: signs and symptoms of onset
The initial or prodromal phase of herpes zoster ophthalmic is non-specific and is hardly distinguished from a common flu-like syndrome.
The signs and symptoms with which ophthalmic herpes zoster begins include:
- Tingling at the forehead level;
- Fatigue (asthenia) and easy fatigability;
- General malaise .
These manifestations last for about a week and may be associated with ophthalmic disorders, comparable to those of viral-type infective conjunctivitis, including:
- Eye pain ;
- Photophobia (hypersensitivity to light);
- Blurring of sight ;
- Sense of foreign body ;
- Abundant watering ;
- Eye redness.
After a few days, herpes zoster ophthalmic produces a unilateral eruption on the forehead and upper eyelid : in patients erythematous skin macules appear, which progress in groups of papules and vesicles . The latter have a serous or hemorrhagic content and, by breaking, give rise to scabs that heal in two or three weeks, but, in rare cases, have a chronic course and can persist even for years. The rash distribution is dermatomeric : the lesions typically run along the ophthalmic branch of the V cranial nerve.
Acute phase: how does it manifest itself?
During the acute phase of herpes zoster ophthalmic, painful inflammation of the eyelids ( blepharitis ) and anterior ocular structures ( uveitis and superficial keratitis ) and, rarely, posterior inflammation take place.
This inflammatory process, in addition to severe pain in and around the eye, causes various ophthalmic signs, including:
- Eyelid edema (swelling of the eyelids);
- Eyelid ptosis (ie the eyelid is lowered than the norm);
- Redness of the conjunctiva;
- Hyperemia of the episclera and cornea;
- Corneal edema;
- Increased intraocular pressure;
- Pinching sensation in the peri-ocular site (around the eye) or at the level of the scalp.
Corneal lesions and uveitis can be important and lead to scar formation and corneal neo-vessels with significant impairment of vision.
Herpes zoster ophthalmic: possible complications
The relapsing forms of herpes zoster ophthalmic are generally more aggressive: the pathology can cause deep corneal ulcers, permanent scars and reduction / loss of vision .
Ocular complications of ophthalmic herpes zoster include:
- Glaucoma;
- Cataract;
- Chronic or recurrent uveitis;
- Scars and corneal neovascularization;
- Retinal detachment (not frequent).
The development of these conditions can be risky for vision. Rarely, herpes zoster ophthalmic causes irreversible damage or corneal lacerations.
Another possible consequence is post-herpetic neuralgia, responsible for very debilitating pains, which may persist for months or years in the region involved.
Diagnosis
The diagnosis of ophthalmic herpes zoster is usually clinical and involves the collection of anamnestic data, an eye examination and the identification of the characteristic signs of the disease, such as the pain referred by the patient and the dermatomical eruption on the forehead and on the eyelid, in association with other eye symptoms. As support, culture and immunological examinations can also be performed.
history
In case of suspected ophthalmic herpes zoster, the doctor will carefully evaluate the symptomatology reported by the patient and his clinical history, focusing in particular on the research of past herpetic infections.
Objective Examination
The symptoms and lesions that characterize ophthalmic herpes zoster lend themselves to a fairly univocal interpretation. Usually, a visual inspection of the affected area by the physician is sufficient to understand the extent of eye involvement.
The patient's eye is generally examined with an instrument called the ophthalmoscope, which is useful for examining the deepest part, the optic nerve and the blood vessels. The slit lamp is an instrument consisting, instead, of a light source and a magnifying glass that displays the internal ocular structures in detail, so it is useful for evaluating possible corneal abrasions / ulcerations.
Other investigations
In general, it is not necessary to resort to laboratory tests, but the diagnosis is sometimes complicated by the fact that some patients present only the ocular signs and symptoms.
In the presence of suspicious symptoms or doubts about the viral etiology, the doctor can take a sample from the conjunctiva or ocular secretion for a subsequent cytological (cellular) laboratory investigation . To ascertain that the infectious agent is indeed an ophthalmic herpes zoster, it is also possible to collect the material from the vesicles for a search of the VZV antigen by direct immunofluorescence assay . Another possible test is a blood test for the research of immunoglobulins, then antibodies, specifically related to the presence of varicella-zoster virus (VZV). In other cases, instead, it is possible to carry out the viral particle dosage by PCR, ie amplifying its DNA.
Treatment
The treatment of ophthalmic herpes zoster fundamentally depends on the extent of the infection and on the degree of involvement of the eye (superficial cornea, deep cornea, retina, iris etc.).
Usually, the treatment uses antiviral drugs (eg aciclovir, famciclovir, valaciclovir etc.) and corticosteroids, on medical prescription.
- If the involvement is superficial, it can be easily eradicated with the application of ophthalmic ointments or antiviral eye drops, to reduce the severity of the manifestations and accelerate the recovery times from shingles. In this regard, an important recommendation to shorten the duration of the events is to start this treatment as soon as possible.
- In severe cases, topical treatment could be strengthened by oral antiviral drugs .
- The use of cortisone-based eye drops is reserved exclusively for severe cases of ophthalmic herpes zoster (involvement of the corneal stroma): in similar circumstances, patients must strictly follow the instructions given by the doctor. Inordinate or inadequate use of these drugs can paradoxically aggravate the symptoms.
To control the pain associated with herpes zoster ophthalmic, analgesic and anti-inflammatory drugs can be used.
If there is a risk of incurring some bacterial superinfection, however, the doctor may recommend antibiotic-based eye drops for exclusively prophylactic purposes.
If corneal scars secondary to ophthalmic herpes zoster do not respond to pharmacological treatment, corneal surgery or transplantation may be necessary.
