What is herpes zoster (shingles) ophthalmicus (HZO)?

Updated: Feb 11, 2021
  • Author: Camila K Janniger, MD; Chief Editor: Dirk M Elston, MD  more...
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HZO results from viral invasion of the Gasserian ganglion and accounts for 10-15% of zoster cases. [58] In addition to the classic symptoms and lesions of herpes zoster, common manifestations of HZO include conjunctivitis, scleritis, episcleritis, keratitis iridocyclitis, Argyll-Robertson pupil, glaucoma, retinitis, choroiditis, optic neuritis, optic atrophy, retrobulbar neuritis, exophthalmos, lid retraction, ptosis, and extraocular muscle palsies.

HZO develops when cranial nerve (CN) V (ie, the trigeminal nerve) is involved in viral reactivation. For unknown reasons, involvement of the ophthalmic branch of this nerve (V1) is 5 times as common as involvement of the maxillary branch (V2) or the mandibular branch (V3). HZO is easily recognized on the basis of vesicular and erythematous involvement of the CN V1 dermatome, ipsilateral forehead, and upper eyelid (see the image below). When lesions are found in the CN V1 dermatome, a slit-lamp examination is done to identify corneal findings.

Herpes zoster in ophthalmic (V1) distribution of t Herpes zoster in ophthalmic (V1) distribution of trigeminal nerve. Note unilateral distribution of rash and how V1 distribution may extend to tip of nose. Though at risk for keratitis with zoster in this distribution, patient had normal ocular examination. Patient consented to picture distribution for educational use; written permission on file. Image courtesy of JS Huff.

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