Chicken pox is caused by the varicella zoster virus. The same varicella zoster virus can recur decades later causing shingles, most commonly on the trunk of the body.
When it occurs around the eye, it is called herpes zoster ophthalmicus (HZO). It often begins with a tingling or burning sensation of the scalp, forehead or cheeks. A few days later it may break out into a painful rash. If caught within the first few days of the rash, shingles is treated with antiviral pills. HZO can also affect the eyeball and cause inflammation in the front or back of the eye, and also glaucoma.
Depending on the exact ocular involvement, shingles in the eye may be treated with a variety of medications including steroids. As in the treatment of herpes simplex keratitis, if steroids are used, they often need to be decreased very slowly, frequently over months to years. Shingles may also cause chronic skin sensitivity or pain, termed postherpetic neuralgia (PHN). PHN often subsides over months, but if not, certain medications can be helpful.
Herpes zoster ophthalmicus (HZO). Also called ocular shingles. When it involves the cornea, it is termed herpes zoster keratitis.
Chicken pox is caused by the varicella zoster virus. The same varicella zoster virus can recur decades later causing shingles, most commonly on the trunk of the body. It can also affect the cornea and cause inflammation in the front or back of the eye and glaucoma.
HZO often begins with a tingling or burning sensation of the scalp, forehead or cheeks. A few days later it may break out into a painful one-sided rash in the scalp, forehead and around the eye. When the eye is involved there that can be redness, foreign body sensation, light sensitivity, pain, discharge, and mild to severe decreased vision.
Video Transcript - November 2017
Christopher J. Rapuano, MD - Hi I'm Dr. Christopher Rapuano, Chief of the cornea service at Wills Eye Hospital and I'm here with my associate Beeran Meghpara, MD also on the cornea service at Wills Eye Hospital. We are coming to from The Wills Eye Alumni Society Newsroom at Wills Eye Hospital in Philadelphia. We are here today to talk about shingles. Shingles around the body and especially shingles around the eye and also ways to prevent it. Beeran can you tell us a little bit about Shingles around the body and also in the eye.
Beeran Meghpara, MD - Sure Chris I would love to. So Shingles it actually first starts out as Chicken Pox. We are all exposed to Chicken Pox at a young age and then it goes dormant in the body and years later maybe in the 50s, 60s, 70s for reasons that we really don't know why it becomes reactivated in the form of the shingles virus. The way shingles typically presents is with the rash, either on the body, on the face and it's often a painful rash. Sometimes it can be minor and sometimes it can be quite severe. But it can affect other things as well you can once the rash goes away you can get something called postherpetic neuralgia which is a painful condition that that can take months and months ago and sometimes it never goes away.
Dr. Rapuano - It is a severe pain sometimes that is just devastating to patients.
Dr. Meghpara - difficult-to-treat.
Dr. Rapuano - What about in the eye, what if shingles gets in the eye, is that a problem or does it go away kind of.
Dr. Meghpara - Shingles in the eye can be very tricky problem. It can affect all parts of the eye. It can affect the front of the eye, the cornea. It can affect the structures inside the eye like the Retina and if not treated quickly and effectively it can lead to vision loss.
Dr. Rapuano - And Glaucoma is another issues that you can get so it can affect all kinds of problems in the eye. Shingles seems to be more prevalent, more common now than 10, 15, 20 years ago not only in the US but around the world and again we don't know exactly why that is. Is there any ways to prevent shingles?
Dr. Meghpara - There is there's actually a very good way to prevent shingles there is a shingles vaccine that is available for about the last 10 years called Zostavax. It's done a very good job. The Zostavax is recommended in patients 16 + and it reduces the risk of getting shingles by about 50%.
Dr. Rapuano - Is that 50% in all comers from 50, 60, 70, 80, 90 or is there a difference.
Dr. Meghpara - That’s a good question it's actually amongst the entire population one of the issues with the Zostavax is as our patients get older the effectiveness of the vaccine goes down. The other nice thing about the Zostavax is, even if you do get the shingles virus the severity of the infection sometimes less and reduces the risk of getting this postherpetic neuralgia by about 66%.
Dr. Rapuano - That's good now Zostavax is a live attenuated a weakened virus it is not recommended in patients who are immunocompromised so there is a subset of our patients that are really not great for the Zostavax.
Dr. Meghpara - Exactly and that's an issue because it's often these immunocompromised patients that are at higher risk for getting the shingles virus.
Dr. Rapuano - Anything new with vaccines.
Dr. Meghpara - Yes we are quite excited about this there's been a newly FDA approved immunization for shingles called the Shingrix recently approved I think about a month ago. The reason we're excited about this and the CDC is is excited about it as well is that it is seems to be more effective in preventing the virus. The studies tell us that about 97% of the patients that get this virus will not get shingles. The great thing is this effect tends to last longer in life so even patients 70 and older it has about a 90% effectiveness.
Dr. Rapuano - That's great that's a big difference and also it's not a live virus, it’s kind of a subunit it’s particles. So theoretically and we expect it to be good for patients who are immunocompromised. Is this available right now, can you go get it today?
Dr. Meghpara -It's not available right now but I believe you spoke with the manufacturer, what did they say?
Dr. Rapuano - I spoke to the manufacturer just yesterday and they told me they hope it is available by the end of November 2017. In the pretty near future we hope it is available to patients. How is it done exactly, is it one shot, multiple shots?
Dr. Meghpara - Sure this is one of the downsides of this new vaccine it does need to be administered into two separate dose.s I believe they're supposed to be 8 weeks apart. The other thing about this vaccine that that we read about is it does tend to be a little bit more painful when getting the injection. Typically people reporting soreness at the injection site for about 2 days and there are a few systemic side effects like fevers, muscle aches, joint aches but they typically go away by themselves in 2 days. Certainly a little bit of discomfort little bit of pain certainly outweighs the potential pain and morbidity from an actual shingles infection.
Dr. Rapuano - Shingles infections are absolutely terrible in the whole body and they're even worse with more severe complications and side effects in the eye. My prior partner, a cornea specialists, got shingles in her eye and caused such problems actually that she had to stop practicing medicine, so it is really potentially devastating.
Dr. Rapuano - Thank you very much. This is wonderful news for medicine in general and ophthalmology specifically and we're hoping to have this new vaccine available to us in the near future and certainly reccommend this to our patients 50 years and older to decrease the chance of this terrible condition. I am Chris Rapuano, MD and I am here with Beeran Meghpara, MD from the Cornea Service of Wills Eye Hospital in Philadelphia. Thank you very much.
Varicella zoster virus.
Prior chicken pox, increasing age, immunocompromised state.
Corneal scarring and irregularity, corneal blood vessels, corneal ulceration and perforation, iritis/uveitis, retinal involvement, severe decreased vision or blindness. Shingles may also cause chronic skin sensitivity or pain, termed postherpetic neuralgia (PHN).
Tests and Diagnosis
Careful examination of the scalp and forehead skin. Slit lamp examination is essential. An examination of the back of the eye should also be performed when HZO is first diagnosed.
If caught within the first few days of the rash, shingles is treated with a 7-10 day course of antiviral pills. Steroid drops are indicated is there is significant inflammation; they often need to be decreased very slowly, frequently over months or years. Post-herpetic neuralgia (PHN) may need to be treated with creams or systemic medications, and occasionally referral to a pain management specialist.
The shingles vaccine is FDA approved for patients over the age of 50 years. We recommend it as it decreases the risk of HZO and also decreases the severity of HZO in those patients who get it after having received the vaccine.