Trigeminal Herpes Zoster
- Infection by herpes zoster of anterior scalp, forehead, upper lid, nose, eye (first trigeminal dermatome)
- Activation of dormant virus in trigeminal ganglion
- Occurs mostly over age 60 and in immune-compromised
- Ophthalmic manifestations: lid vesicles, conjunctivitis, keratitis, uveitis, optic neuropathy, ophthalmoplegia
- Eye involvement especially common if tip of nose has vesicles ("Hutchinson’s sign")
- Periocular and forehead pain often severe and first manifestation
- Forehead vesicles
- Lid vesicles, like skin vesicles, that quickly become encrusted
- Corneal surface erosions ("epithelial keratitis") and opacities ("stromal keratitis")
- Cells and flare evident in slit lamp beam in anterior uveitis
- Elevated or depressed intraocular pressure secondary to uveitis
- Vision loss with afferent pupil defect in optic neuropathy
- Reduced eye movement sometimes with ptosis and mydriasis in ocular motor cranial nerve palsy
- Herpes simplex infection, but vesicles do not "respect" boundaries of trigeminal dermatome
- Impetigo (infected scratch or bite), but eye is spared
- Orbital infection or tumor, but skin is spared
- Refer to ophthalmologist to rule out eye involvement even if patient has no visual symptoms
- Diagnosis based on finding vesicular dermatomal rash
- Treatment of immune-competent patients: oral antiviral agent (acyclovir 800mg 5x daily for 7-10 days or equivalents)
- Treatment of disseminated zoster infection and of immune-compromised patients: intravenous acyclovir
- Treatment of anterior uveitis or stromal keratitis: topical corticosteroid
- Early antiviral treatment reduces likelihood of eye involvement and post-herpetic neuralgia