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Herpes zoster in neuro-ophthalmology: a practical approach

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Abstract

Herpes Zoster (HZ) or shingles is the reactivation of the Varicella Zoster Virus (VZV), usually along a single sensory nerve, but can affect both sensory and motor cranial nerves. Major risk factors for HZ include immunosuppressed status and age older than 60 years. In the United States, the lifetime risk of HZ is approximately 30%. Worldwide, the median incidence of HZ is 4–4.5 per 1000 person-years across the Americas, Eurasia, and Australia. HZ ophthalmicus, occurring in 10–20% of patients, is an ophthalmic emergency characterized by VZV reactivation along the V1 branch of the trigeminal nerve. Approximately half of this patient subgroup will go on to develop ocular manifestations, requiring prompt diagnosis and management. While anterior segment complications are more common, neuro-ophthalmic manifestations are rarer and can also occur outside the context of overt HZ ophthalmicus. Neuro-ophthalmic manifestations include optic neuropathy, acute retinal necrosis or progressive outer retinal necrosis, cranial neuropathy (isolated or multiple), orbitopathy, and CNS manifestations. Although typically a clinical diagnosis, diagnosis may be aided by neuroimaging and laboratory (e.g., PCR and serology) studies. Early antiviral therapy is indicated as soon as a presumptive diagnosis of VZV is made and the role of corticosteroids remains debated. Generally, there is wide variation of prognosis with neuro-ophthalmic involvement. Vaccine-mediated prevention is recommended. In this review, we summarize neuro-ophthalmic manifestations of VZV.

摘要

带状疱疹 (Herpes Zoster, HZ) 或带状疱疹 (shingles) 是再次激活的水痘带状疱疹病毒 (VZV), 沿着单个感觉神经影响感觉神经和运动脑神经的一种神经性疾病。HZ的主要危险因素包括免疫抑制状态和年龄60岁以上的老年人。在美国, HZ的终生风险约为30%。在全球范围内, 美洲、欧亚大陆和澳大利亚的HZ发病率中位数为每年每1000人4-4.5例。发生眼内炎的几率为10-20%。HZ也是一种眼科急症, 其特征是沿三叉神经V1分支的VZV病毒激活后产生的 (病变) 。患者中约有一半会出现眼部表现, 需要及时诊断和治疗。眼前段并发症更为常见, 神经眼科较为罕见, 也可能发生眼部不受累的情况。神经眼科的临床表现包括视神经病变、急性视网膜坏死或进行性视网膜外层坏死、脑神经病变 (孤立性或多发性) 、眼眶病和中枢神经系统表现。尽管可根据典型的临床表现进行诊断, 神经影像学和实验室 (如聚合酶链式反应和血清学) 结果可提供重要的辅助性临床诊断资料。一旦待确诊VZV, 需及早的抗病毒治疗, 但目前皮质类固醇的作用仍有争议。一般来说, 神经眼科病变者的预后差异很大。建议通过疫苗进行预防。在这篇综述中, 我们总结了VZV的神经眼科表现。

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Fig. 1: HZO with Hutchinson Sign, a highly suggestive sign of ocular adnexal disease, raising suspicion for neuro-ophthalmic manifestations.
Fig. 2: MRI imaging of a patient with right VZV optic neuropathy.
Fig. 3: Ocular motility in a patient with VZV-induced third nerve palsy.
Fig. 4: Ocular motility in a patient with VZV affecting the left cavernous sinus and orbit.
Fig. 5: Case of a patient with fixed third nerve palsy, mild sixth nerve palsy, and V1 anesthesia.
Fig. 6: Left panel: angiography of large-vessel VZV vasculopathy, chiefly occurring in elderly immunocompetent patients.

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Funding

This work received no direct financial support. BT is supported by the Eye Foundation of Canada.

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Authors and Affiliations

  1. Faculty of Medicine, The University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada

    Brendan Ka-Lok Tao

  2. Faculty of Arts & Science, University of Toronto, 100 St. George Street, Toronto, ON, M5S 3G3, Canada

    Deep Soor & Jonathan A Micieli

  3. Department of Ophthalmology and Vision Sciences, University of Toronto, 340 College Street, Toronto, ON, M5T 3A9, Canada

    Jonathan A Micieli

  4. Division of Neurology, Department of Medicine, University of Toronto, 6 Queen’s Park Crescent West, Toronto, ON, M5S 3H2, Canada

    Jonathan A Micieli

  5. Kensington Vision and Research Center, 340 College Street, Toronto, ON, M5T 3A9, Canada

    Jonathan A Micieli

  6. St. Michael’s Hospital, 30 Bond Street, 7 Donnelly Eye Clinic, Toronto, ON, M5B 1W8, Canada

    Jonathan A Micieli

Authors
  1. Brendan Ka-Lok Tao
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  2. Deep Soor
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  3. Jonathan A Micieli
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Contributions

Conception/Design/Acquisition/Analysis/Interpretation (BT, JM), Acquisition (BT, JM), Drafting/Revision (all authors), Final Approval (all authors), Agreement of Accountability (all authors). Authorship: All authors attest that they meet the current ICMJE criteria for authorship.

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Correspondence to Jonathan A Micieli.

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Tao, B.KL., Soor, D. & Micieli, J.A. Herpes zoster in neuro-ophthalmology: a practical approach. Eye (2024). https://doi.org/10.1038/s41433-024-03030-3

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