Chief Complaint: Eye Pain
A. History: Located in the Periorbital Area
Differential Diagnosis
Herpes Ophthalmicus,
| Pivotal Assessment | Finding |
|---|---|
Further History |
Herpes zoster ophthalmicus (HZO) is a reactivation of the varicella-zoster virus (VZV) involving the ophthalmic division (V1) of the trigeminal nerve. Early and accurate diagnosis is essential to prevent ocular complications.
Prodrome: Pain, burning, or tingling in the forehead, scalp, or around the eye (typically 1–5 days before rash).
Acute symptoms: Red eye, tearing, blurred vision, photophobia.
Other: History of prior chickenpox or exposure to VZV; immunosuppressed state.
Rash: Vesicular eruption in the V1 dermatome (forehead, upper eyelid, tip of the nose).
Hutchinson’s sign: Vesicles on the tip or side of the nose indicate nasociliary nerve involvement and higher risk of ocular complications.
Ocular findings:
Conjunctivitis
Episcleritis or scleritis
Keratitis (punctate or dendritic lesions)
Uveitis
Elevated intraocular pressure (IOP)
May reveal:
Dendritic keratitis (can resemble herpes simplex but usually has smaller, finer dendrites with tapered ends)
Stromal keratitis
Anterior uveitis
Endotheliitis
PCR of vesicle fluid or corneal scrapings to detect VZV DNA
Direct fluorescent antibody (DFA) testing
Tzanck smear: Shows multinucleated giant cells (non-specific, also seen in HSV)
Serology: May be supportive but not diagnostic of acute infection
Rarely used unless ruling out other causes (e.g., orbital cellulitis or CNS involvement).
Always, if the eye is involved or there's periorbital edema, decreased vision, or Hutchinson’s sign.
Prompt referral is critical to prevent long-term complications like vision loss or chronic pain.
Let me know if you want a treatment guide or differential diagnosis list too.