Herpes zoster (Shingles) neuro-ophthalmology

Key Takeaways

  • Herpes zoster (shingles) can cause damage to the eye, including neuro-ophthalmic complications.
  • The authors recommend getting the vaccine to prevent the disease and its complications.

Most adults have Varicella Zoster Virus (VZV, chicken pox) while they are children.  The virus can hide in a sleeping (dormant) form in nerves.  It can wake up years later when it appears as Shingles.  At that point, it is called Herpes Zoster (HZ) and can affect both the eye and other sensory and motor cranial nerves. Major risk factors for HZ include being immunocompromised, or being 60 or older. In the United States, the lifetime risk of HZ is approximately 30%. Worldwide, HZ occurs across the Americas, Eurasia, and Australia. 

HZ ophthalmicus (of the eye), occurring in 10-20% of patients, is an eye emergency characterized by VZV reactivation along the V1 branch of the trigeminal nerve. Approximately half of these patients will go on to develop eye symptoms, requiring prompt diagnosis and management. Front of the eye complications are more common while neuro-ophthalmic manifestations are rare. Neuro-ophthalmic manifestations include optic neuropathy (damage to the optic nerve), acute retinal necrosis (death of retinal tissue) or progressive outer retinal necrosis, cranial neuropathy (damage to cranial nerves), orbitopathy (swelling), and central nervous system (brain) manifestations. Although typically a clinical diagnosis, diagnosis of neuro-ophthalmic complications may be aided by neuroimaging and laboratory studies.

Early antiviral therapy is indicated as soon as a presumptive diagnosis of VZV is made. However, the role of corticosteroids remains debated. Generally, there is wide variation of prognosis with neuro-ophthalmic involvement. Vaccine-mediated prevention is recommended.

Source: Tao, B.KL. et al, Eye, March 27, 2024, doi:10.1038/s41433-024-03030-3