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Neurological and Ophthalmological Manifestations of Varicella Zoster Virus

Kedar, Sachin, MD; Jayagopal, Lakshman N., MBBS; Berger, Joseph R., MD

Section Editor(s): Costello, Fiona MD, FRCP(C); Prasad, Sashank MD

Journal of Neuro-Ophthalmology: June 2019 - Volume 39 - Issue 2 - p 220–231
doi: 10.1097/WNO.0000000000000721
State-of-the-Art Review

Background: Approximately 1 million new cases of herpes zoster (HZ) occur in the United States annually, including 10%–20% with herpes zoster ophthalmicus (HZO). Postherpetic neuralgia, a debilitating pain syndrome occurs in 30% HZ, whereas 50% HZO develop ophthalmic complications. Diplopia from cranial nerve palsy occurs in less than 30% HZO, whereas optic neuropathy is seen in less than 1% HZO. We reviewed recent developments in the diagnosis, treatment, and prevention of HZ as well as neurological and ophthalmological complications of relevance to the neuro-ophthalmologist.

Evidence Acquisition: We searched the English language literature on Pubmed and Google scholar for articles relevant to the various sections of this review.

Results: Antiviral treatment should be initiated within 48–72 hours of onset of HZ and HZO to decrease pain and reduce complications. We recommend neuroimaging in all patients with neuro-ophthalmic manifestations such as diplopia and acute vision loss. Diagnostic confirmation using polymerase chain reaction and serology on paired serum and cerebrospinal fluid samples should be obtained in those with neurological signs and symptoms or abnormal imaging. Patients with neurological and/or retinal varicella zoster virus (VZV) infection should be treated promptly with intravenous acyclovir. Patients with isolated optic neuropathy or cranial nerve palsy can be managed with oral antivirals. The prognosis for visual recovery is good for patients with isolated optic neuropathy and excellent for patients with isolated ocular motor cranial nerve palsy.

Conclusions: HZ produces a spectrum of potentially blinding and life-threatening complications that adversely affect quality of life and increase health care costs. Individuals at risk for HZ, such as the elderly and immunocompromised, should be encouraged to receive the highly effective VZV vaccine to prevent HZ and its complications.

Department of Neurological Sciences (SK, LNJ), University of Nebraska Medical Center, Omaha, Nebraska; Stanley M Truhlsen Eye Institute (SK), University of Nebraska Medical Center, Omaha, Nebraska; and Department of Neurology (JRB), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.

Address correspondence to Sachin Kedar, MD, Nebraska Medical Center, Omaha, NE 68198-8435; E-mail:

S. Kedar, reports being a coinventor for the Advanced Pupil Simulator licensed by EON Reality Inc. J. R. Berger, grants from Biogen, during the conduct of the study; personal fees from Amgen, personal fees from Astra-Zeneca, personal fees from Janssen, personal fees from Millennium/Takeda, personal fees from Novartis, personal fees from Biogen, personal fees from Roche, personal fees from Genentech, personal fees from Genzyme/Sanofi, personal fees from Inhibikase, personal fees from Forward Pharma, personal fees from Johnson and Johnson, personal fees from Pfizer, and personal fees from Eisai, outside the submitted work. The remaining author reports no conflicts of interest.

© 2019 by North American Neuro-Ophthalmology Society