herpes zoster ophthalmicus require ophtho consult

This patient presents with headache, malaise, fever, and a skin rash, all highly suggestive of herpes zoster.  The vesicular, crusty skin eruption on her forehead also involves the eyelids, with evidence of edema and drooping.  She is at risk of developing herpes zoster ophthalmicus (HZO).  HZO is a serious, vision-threatening complication of reactivation of varicella zoster virus in the trigeminal nerve root ganglion.  Some patients present with headache, malaise, eye pain, and fever before developing a rash on the face.  Once the rash develops, patients can also have conjunctivitis, keratitis, or episcleritis.  Vesicles near the nose are also associated with a high risk of HZO.

Patients at risk for herpes zoster ophthalmicus require an urgent ophthalmology consultation.  Immunocompromised patients with sight-threatening ophthalmicus should receive intravenous acyclovir.  When urgent evaluation by an ophthalmologist is not available, topical steroid eye drops can be used to decrease the inflammatory response.

Systemic glucocorticoids, when used in combination with antiviral therapy for treatment of herpes zoster, can increase the risk of secondary bacterial skin infections.  They are not recommended in this patient.