Original article
Herpes Zoster Ophthalmicus: Natural History, Risk Factors, Clinical Presentation, and Morbidity

https://doi.org/10.1016/j.ophtha.2007.10.009Get rights and content

Topic

The incidence and morbidity of herpes zoster (HZ) and HZ ophthalmicus (HZO), and the potential impact of varicella vaccine on their epidemiology.

Clinical Relevance

Herpes zoster affects 20% to 30% of the population at some point in their lifetime; approximately 10% to 20% of these individuals will have HZO.

Methods

The peer-reviewed literature published from 1865 to the present was reviewed.

Results

Herpes zoster is the second clinical manifestation of varicella-zoster virus (VZV). The incidence and severity of HZ increase with advancing age. Varicella-zoster virus–specific cell-mediated immunity, which keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an important mechanism in preventing VZV reactivation as zoster. Thus, widespread varicella vaccination may change the epidemiology of HZ. Herpes zoster ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth cranial nerve. Ocular involvement occurs in approximately 50% of HZ patients without the use of antiviral therapy. There is a long list of complications from HZ, including those that involve the optic nerve and retina in HZO, but the most frequent and debilitating complication of HZ regardless of dermatomal distribution is postherpetic neuralgia (PHN), a neuropathic pain syndrome that persists or develops after the zoster rash has resolved. The main risk factor for PHN is advancing age; other risk factors include severe acute zoster pain and rash, a painful prodrome, and ocular involvement. Many cases of HZ, HZO, and PHN can be prevented with the zoster vaccine.

Conclusion

Vaccination is key to preventing HZ, HZO, and PHN, but strategies for both varicella and HZ vaccines will need to be evaluated and adjusted periodically as changes in the epidemiology of these VZV diseases become more evident.

Section snippets

Varicella

Varicella is characterized by fever, myalgias, anorexia, headache, sore throat, and an acute infectious exanthema with a vesicular eruption of the skin. Before the varicella vaccine was introduced, chickenpox developed in almost all children, producing an incidence equivalent to the United States birth rate at the time, albeit many cases are mild and unrecognized as chickenpox. Although many parents or children may not remember or may not have recognized their prior varicella in the

Herpes Zoster

Herpes zoster is the second clinical manifestation of VZV infection and occurs only in individuals who have had primary VZV infection (varicella) by either wild-type or vaccine-type VZV. Although HZ is not a reportable disease, it is estimated that 1 million or more cases occur each year in the U.S.6, 7, 8, 9 Herpes zoster exhibits no seasonal pattern, confirming that the disease results from the reactivation of latent virus rather than new exposure to VZV. It has been predicted that the

Risk Factors for Herpes Zoster

The virulence of the specific VZV strain may influence the extensiveness and efficiency of the establishment of latent VZV infection in dorsal root ganglia during varicella, but the host factors are more important in determining whether the individual with a latent infection develops symptomatic VZV reactivation as HZ. The incidence and severity of HZ increase with advancing age, especially in those older than 60 years.6, 19 Approximately 20% to 30% of the general population develop HZ at some

Herpes Zoster Ophthalmicus

Herpes zoster ophthalmicus is defined as HZ involvement of the ophthalmic division of the fifth cranial nerve. The ophthalmic division further divides into the nasociliary, frontal, and lacrimal branches, of which the frontal nerve is most commonly involved with HZO.41 The nasociliary nerve innervates the anterior and posterior ethmoidal sinuses, skin of both eyelids and the tip of the nose, conjunctiva, sclera, cornea, iris, and choroid. Hutchinson’s sign is defined as skin lesions at the tip,

Postherpetic Morbidity

The most frequent debilitating and perhaps refractory complication of HZ is PHN, a neuropathic pain syndrome that persists or develops after the dermatomal rash has healed.59, 60, 61 Postherpetic neuralgia has a variety of definitions in the literature, including pain persisting from 1 month after rash onset, pain persisting after rash resolution, pain at 3 to 6 months after the acute episode, pain persisting 1 year after the acute episode, and pain differing from acute pain.62, 63 The pain has

Varicella-Zoster Virus Vaccines and Effect on Herpes Zoster

Before the varicella vaccine was introduced, almost every child in the U.S. developed chickenpox. Varicella vaccine coverage has increased steadily, reaching 67.8% nationally in 2000 among 19- to 35-month-olds.76 Since introduction of this recommended childhood vaccine, hospitalizations due to varicella have declined by 88% and ambulatory visits by 59%.3, 5, 76 Hospitalizations and ambulatory visits declined in all age groups, with the greatest declines among infants younger than 1 year. Total

Conclusion

Herpes zoster is the second clinical manifestation of VZV. The incidence and severity of HZ increase with advancing age. Varicella-zoster virus–specific CMI, which keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an important mechanism in preventing VZV reactivation as zoster. Herpes zoster ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth cranial nerve. Without the use of antiviral therapy, approximately 50% of HZ patients develop ocular

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