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Purpose: To describe our experience with the use of a sustained-release dexamethasone implant in three patients with recalcitrant macular edema that developed after necrotizing retinitis in the context of the previously treated virus., Case Description: Two immunocompetent patients presented with unilateral acute retinal necrosis (ARN) due to Varicella-Zoster (VZV). The other, an immunocompromised patient, presented with unilateral cytomegalovirus (CMV) necrotizing retinitis. The diagnoses were confirmed by anterior chamber polymerase chain reaction (PCR) and all were treated with oral valganciclovir and intravitreal ganciclovir (2 mg/0.1 ml). Infection was controlled but two of them required pars plana vitrectomy. Between 2 and 4 months after the resolution of signs of infection, resistant macular edema (RME) developed, and an intravitreal dexamethasone device was implanted after anterior chamber PCR had been negative. Functional and anatomical improvement was achieved, with the resolution of the edema accompanied by improvement in visual acuity in all patients. There was no evidence of reactivation at two years. No cataract or ocular hypertension was observed. One patient required two additional dexamethasone implants., Conclusion: Dexamethasone intravitreal implant could be considered as an option for the treatment of macular edema developed after ARN. Care should be taken to avoid reactivation and patients need to be properly informed., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Cases of herpes zoster ophthalmicus (HZO) complicated by bilateral ophthalmoplegia are rare, and no cases of bilateral third, fourth, or sixth cranial nerve palsies have been reported. Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a rare complication of HZO. We herein report an 80-year-old Japanese woman with right-sided HZO complicated by meningoencephalitis and discuss the pathogenesis of this condition. She developed bilateral third, fourth, and sixth cranial nerve palsies and SIADH almost simultaneously during treatment for HZO. The bilateral cranial palsy spontaneously resolved within a few months.

Background: Up to 1/3 of patients with herpes zoster ophthalmicus (HZO) may develop ophthalmoplegia. Although zoster-related ophthalmoplegia (ZO) is typically treated with antiviral agents, there is controversy regarding the therapeutic role of systemic steroids., Methods: This was a retrospective case series and case report-based systematic review. For the case series, participants were recruited from tertiary neuro-ophthalmology clinics. Eligible participants were those who developed cranial nerve palsies (CNP) within 1 month of HZO diagnosis. In the systematic review, all adults with ZO in the literature who were treated with antivirals or steroids only, or combination therapy were included. Main outcomes were initial presentation, investigations, neuroimaging, treatment regimen, and final outcomes of ophthalmoplegia., Results: Eleven immunocompetent patients with ZO were included. The most common CNP was CN III (5/11), followed by CN VI (2/11) and CN IV (2/11). One patient had multiple CNPs. All patients were treated with antivirals, and 4 also treated with a short course of oral steroids. At 6-month follow-up, 75% of patients treated with combination therapy and 85.7% treated with antivirals alone had complete recovery of ZO. The systematic review identified 63 studies consisting of 76 cases of ZO. When comparing patients treated with antivirals with those treated with antivirals and steroids, patients on combination therapy had more severe ocular findings, including complete ophthalmoplegia ( P < 0.001). Age was the only significant predictor of complete recovery of ophthalmoplegia on multivariable logistic regression ( P = 0.037)., Conclusions: The rate of complete recovery in immunocompetent patients with ZO was similar in patients treated with antivirals alone vs those treated with antivirals and oral steroids. The systematic literature review affirmed these findings. However, age may influence recovery of ophthalmoplegia., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by North American Neuro-Ophthalmology Society.)

Introduction: In this report, we describe a rare case of a cranial nerve VI palsy secondary to herpes zoster infection with polyneuropathic involvement., Case Presentation: An 82-year-old male was seen by ophthalmology for acute onset of double vision. Fourteen days before presenting, he was diagnosed with herpes zoster ophthalmicus. He was suspected to have zoster polyneuropathy also involving cranial nerve IX and X given a sore throat that began prior to the characteristic trigeminal dermatomal rash. He was diagnosed with cranial nerve VI palsy secondary to herpes zoster infection., Discussion: Ophthalmic complications of herpes zoster ophthalmicus are many; however, extraocular nerve palsies secondary to herpes zoster infection and zoster polyneuropathy are documented infrequently in the literature., Conclusions: Extraocular muscle palsies are a rare complication of herpes zoster infection. This case reviews the most current literature surrounding this condition and discusses the significance of polyneuropathic involvement in varicella zoster virus reactivation., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Herpes zoster ophthalmicus (HZO) occurs when latent varicella zoster virus reactivates in the ophthalmic division of the fifth cranial nerve (CNV1). HZO commonly affects older and immunocompromised patients. This disease is considered an ophthalmic emergency due to the wide range of associated ocular symptoms, including severe chronic pain and vision loss. HZO is typically a clinical diagnosis due to its classic presentation of a unilateral vesicular eruption in the dermatomes corresponding to CNV1. Timely treatment is imperative to minimize ocular morbidity in HZO, given that ocular involvement is present in 50% of affected patients., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The goal of this clinical case is to report a case of ophthalmic zoster in a five-year-old boy and to insist on the relevance of early antiviral treatment (aciclovir) so as to minimize corneal affection and preserve visual function., Observation: We report the case of a five-year-old boy of preschool age with no notable pathological history who came for consultation with a painful eruption affecting the forehead, the upper eyelid, the nose. The clinical examination showed many erythematous vesicles affecting the left hemi-face. The diagnosis of ophthalmic zoster has been retained. Minimum biological laboratory assessment is normal. The treatment was local antiseptic and systemic aciclovir with high dose for ten days. The evolution was favorable. Zoster is rare in children. The ophthalmic form is exceptional. The diagnosis is clinical and should mention some bladdery lesions grouped in bunches with a disposition which follows a metamere. It can be responsible for serious ocular complications., Conclusion: The particularity of our observation is the presence of zoster in an immunocompetent child and the ophthalmic localization, that remains exceptional in children., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Herpes zoster ophthalmicus (HZO) is a kind of refractory disease, and treating it is important for preventing postherpetic neuralgia (PHN). But the evidence surrounding the current treatment options for these conditions is controversial, so exploring reasonable clinical treatment strategies for HZO is necessary. Neuromodulation is an excellent modality for the treatment of various neuropathic pain conditions. This trial was designed to evaluate the effectiveness of short-term supraorbital nerve stimulation (SNS) and the supraorbital nerve block (SNB) for HZO., Objectives: To determine whether short-term SNS relieves acute and subacute ophthalmic herpetic neuralgia., Study Design: This prospective randomized controlled crossover trial compared short-term SNS to SNB., Setting: The operating room of a pain clinic., Methods: Patients with acute or subacute ophthalmic herpetic neuralgia were recruited. The patients were randomly assigned to receive either SNS or SNB. The primary outcome being measured was each patient's Visual Analog Scale (VAS) score at 4 weeks. The secondary outcomes under measurement were the proportion of patients who achieved ≥ 50% pain relief, sleep quality, medicine consumption, and adverse events. Crossover after 4 weeks was permitted, and patients were followed up to 12 weeks., Results: Overall, 50 patients were included (n = 25/group). At 4 weeks, the patients who received SNS achieved greater pain relief, as indicated by their significantly different VAS scores from those of the SNB group (mean difference: -1.4 [95% CI, -2.29 to -0.51], P < 0.05). Both groups showed a significant decrease in pain level from the baseline (all P < 0.05). Overall, 72% and 44% of the SNS and SNB patients experienced ≥ 50% pain relief, respectively (OR: 0.31 [95% CI, 0.09 to 0.99], P < 0.05), and 68% and 32% of SNS and SNB patients, respectively, had VAS scores < 3 (OR: 0.22 [95% CI, 0.07 to 0.73], P < 0.05). Compared to the SNB group, the SNS group had better sleep quality, lower ophthalmic neuralgia, a lower proportion of further treatment, and lower analgesic intake. Overall, 18 patients received SNS alone, and 16 patients crossed over from SNB to SNS. The VAS scores, sleep quality, ophthalmic neuralgia, and trend of medicine intake were not significantly different between the groups (all P > 0.05). No serious complications occurred., Limitations: This study was nonblind., Conclusions: Short-term SNS is effective for controlling acute or subacute ophthalmic herpetic neuralgia. Combining SNS with SNB yields no additional benefits.

Introduction: Trigeminal herpes zoster, which comprises 10% to 20% of cases of herpes zoster, often leads to severe pain in the ophthalmic branches. Current treatments, including drug therapy and minimally invasive interventions, have limitations; accordingly, there is a need to explore alternative approaches. This study aimed to evaluate the efficacy and safety of computerized tomography (CT)-guided pulsed radiofrequency of the sphenopalatine ganglion in patients with intractable trigeminal herpetic pain., Patient Concerns: Three patients with intractable trigeminal ophthalmic zoster neuralgia were studied. All patients complained of bursts of headache, which occurred at least 10 times a day, usually in the periorbital and frontal regions. Conventional treatments, including oral medications and radiofrequency therapy targeting the trigeminal-semilunar ganglion and supraorbital nerve, could not sufficiently provide relief., Diagnosis: Two patients were diagnosed with herpes zoster in the ocular branch of the trigeminal nerve with conjunctivitis, while one patient was diagnosed with postherpetic neuralgia in the ocular branch of the trigeminal nerve., Interventions: This study employed a novel approach that involved CT-guided radiofrequency regulation of the pterygopalatine fossa sphenopalatine ganglion., Outcomes: In all three patients, pain relief was achieved within 1 to 3 days after treatment. During the follow-up, one patient had pain recurrence; however, its severity was ≈ 40% lower than the pretreatment pain severity. The second patient had sustained and effective pain relief. However, the pain of the third patient worsened again after 2 months. The average follow-up duration was 3 months. None of the enrolled patients showed treatment-related adverse reactions or complications., Conclusion: Our findings indicated that CT-guided radiofrequency regulation of the pterygopalatine fossa sphenopalatine ganglion was a safe and effective intervention for pain in patients with trigeminal ophthalmic zoster neuralgia, suggesting that it may be a therapeutic option if other treatments fail., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The objective of this study is to report a case of unilateral acute retinal necrosis (ARN) with contralateral eye presenting as non-necrotizing herpetic uveitis., Case Reports: Case 1: A 48-year-old female presented at our clinic with blurred vision in the right eye for 7 days. She was diagnosed with ARN in the left eye 2 weeks ago. Ophthalmic examination revealed reduced visual acuity in the right eye (20/33) with the presence of optic disc swelling and macular exudation without peripheral necrotic lesions. With systemic antiviral therapy, optic disc swelling of the right eye vanished gradually, and the visual acuity improved to 20/20. Loss of retinal nerve fiber layer (RNFL) and decreased retinal thickness in the corresponding area occurred during follow-up., Conclusion: Non-necrotizing herpetic uveitis may occur in the contralateral eye of unilateral ARN under rare conditions. Structure abnormities, including loss of RNFL and focal decreased retinal thickness, are irretrievable.

Competing Interests: The authors declare that there is no conflict of interest.

Purpose: Herpes zoster ophthalmicus (HZO) after COVID-19 vaccination has been reported in numerous case studies. However, no large-scale epidemiologic studies have been conducted to date. The purpose of this study was to determine whether COVID-19 vaccination is associated with an increased risk of HZO., Design: Retrospective before-and-after risk interval analysis., Methods: RESULTS: In total, 1,959,157 patients received a dose of a COVID-19 vaccine during the study period and met eligibility criteria. A total of 80 individuals without a prior history of HZO were included in the analysis because they developed HZO in the risk or control period. Patients had a mean age of 54.0 years (SD = 12.3 years). There were 45 cases of HZO in the risk interval after COVID-19 vaccination. There was not an increased risk of HZO after vaccination with BNT162b2 (IRR = 0.90, 95% CI: 0.49-1.69, P = .74), mRNA-1273 (IRR = 0.74, 95% CI: 0.36-1.54, P = .42), or Ad26.COV2.S (IRR = 0.50, 95% CI: 0.07-2.56, P = .42)., Conclusions: This study found no evidence of increased risk of HZO after COVID-19 vaccination, providing reassurance for patients and providers who may be concerned about the safety profile of the COVID-19 vaccines., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background/objectives: Studies have reported an association between herpes zoster ophthalmicus (HZO) and stroke. We sought to validate this association with rigorous controls for both medical comorbidities and social factors using a nationwide U.S. administrative medical claims database., Subjects/methods: A two-step approach was taken: first a retrospective case-control study was performed, followed by a self-controlled case series (SCCS). For the case control study, cox proportional hazard regression with inverse proportional treatment weighting assessed the hazard for stroke. In the SCCS, incidence of stroke was compared prior to and after the diagnosis of HZO., Results: For the case-control study, 25,720 cases and 75,924 controls met our eligibility criteria. 1712 (6.7%) and 4544 (6.0%) strokes occurred in the case and control groups respectively, conferring an 18% increased risk of stroke in the observed 1-year post-HZO period (HR = 1.18, 95% CI: 1.12-1.25, p < 0.001). SCCS analysis showed the risk for stroke was highest in the month immediately after HZO episode compared to any other time range (1-30 days after, relative risk 1.58, p < 0.001) and even higher when assessing time more distal time points prior to the HZO diagnosis (days 1-30 after HZO diagnosis had RR = 1.69 (95% CI: 1.38-2.07) and RR = 1.93 (95% CI: 1.55-2.39) compared with days -120 to -91 and -150 to -121 prior to index, respectively (p < 0.001)., Conclusions: After accounting for stroke risk factors, our analysis confirms the association between HZO and stroke, with highest risk in the immediate month after an episode., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Competing Interests: The authors report no conflicts of interest.

Herpes zoster ophthalmicus represents a zoster infection in the first division of the trigeminal nerve and has potentially serious complications involving the ocular and orbital structures. Herpes zoster ophthalmicus occurs in approximately 10% to 20% of individuals with herpes zoster and can lead to significant morbidity, particularly in patients with multiple comorbidities. The authors present a case of herpes zoster ophthalmicus along with dacryoadenitis in a patient with uncontrolled diabetes and rheumatoid arthritis who was misdiagnosed, had delayed treatment, and experienced recurrence with orbital symptoms during follow up. Prompt recognition, initiation of therapy and careful monitoring and follow up are important for treating herpes zoster ophthalmicus and preventing recurrence and long-term sequelae., Competing Interests: The authors have no financial or conflicts of interest to disclose., (Copyright © 2023 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.)

Introduction: Ocular involvement due to varicella-zoster virus (VZV) infection includes conjunctivitis, scleritis, keratitis, uveitis, and necrotizing retinitis. Non-necrotizing chorioretinopathy as a late manifestation has been described., Case Report: A 50-year-old immunocompetent man developed herpes zoster ophthalmicus (HZO) in the right V1 dermatome with acute anterior uveitis (AAU) treated with oral valaciclovir and topical steroid and a chalazion in the upper eyelid with associated madarosis. Four months later, he presented recurrence of the AAU and multiple areas of chorioretinal atrophy on fundoscopy. Biopsy of the upper eyelid lesion revealed granulomatous inflammation of the eyelid margin and polymerase chain reaction study (PCR) tested positive for VZV-specific DNA. The iridocyclitis was resolved with oral valaciclovir at maximum doses with minimal choroidal pigmentary changes., Discussion: VZV ophthalmic infection starts by reactivation from the trigeminal ganglion, and it spreads to the isthmus of the pilosebaceous follicles and the epidermis, which can cause involvement of follicle and sebaceous glands. Chorioretinopathy is a rare form of late-onset non-necrotizing herpetic uveitis characterized by atrophic-appearing hypopigmented lesions, the pathogenesis of which is unknown. A direct viral infection or secondary to occlusive choroidal vasculitis is postulated at the level of the choriocapillaris and more recently it has been referred to as "choroidal vitiligo" due to possible involvement of choroidal melanocytes, as occurs in cases of cutaneous vitiligo due to VZV infection.

Cavernous sinus thrombosis is a rare life-threatening complication of herpes zoster ophthalmicus (HZO). This case highlights the importance of at least considering the diagnosis in all cases of HZO, as the consequences of missing it can be disastrous.

Purpose: While typically affecting older adults and immunocompromised individuals, herpes zoster ophthalmicus (HZO) has been reported with varying manifestations and complications in children. In this review, we evaluate reported cases of pediatric HZO in the literature and discuss the epidemiology, risk factors, clinical presentation, treatment and outcomes., Methods: A literature search on PubMed, Scopus, and Web of Science databases was performed using the terms "pediatric herpes zoster ophthalmicus" and "herpes zoster ophthalmicus children." Publications that were not specific to HZO or pediatric populations were excluded, as were publications that were not available to review or not published in the English language., Results: Fifty-seven reports describing 130 cases of HZO or HZO-related complications were reviewed. Major risk factors for pediatric HZO included intrauterine exposure to varicella or primary varicella infection at a young age; HZO also occurred in patients who had received varicella vaccination. Both healthy and immunocompromised children were affected, with the majority of affected children being immunocompetent. The diagnosis of HZO is primarily clinical. Children appear to have good vision recovery and resolution of symptoms if they are treated promptly and if they adhere to treatment regimens, except for irreversible vision loss related to uncommon complications such as optic neuritis., Conclusion: HZO occurs in both healthy and immunocompromised children. Recognizing this treatable condition is essential for reducing ocular and systemic morbidity. Long-term follow-up and assessments of the impact on health in adulthood are lacking. More systematic study is needed to determine the incidence of HZO in children and appropriate diagnostic and treatment protocols for the care of pediatric patients with HZO., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The aim of this study is to report the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management outcomes in a series of three cases of varicella zoster virus (VZV) reactivation following one dose of coronavirus disease 2019 (COVID-19) vaccination. This was a retrospective and observational study. All the patients who developed uveitis post-vaccination were pooled together. Patients who had VZV reactivation were included. Two cases had polymerase chain reaction positive for VZV from aqueous humor. At the time of presentation, IgG and IgM spike protein antibodies for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were tested. Out of this pool, three patients with classical features to describe pole-to-pole manifestations were chosen. A 36-year-old lady with post-vaccination sclerokeratouveitis associated with reactivation of herpes zoster ophthalmicus, a 56-year-old lady with post-vaccination acute anterior uveitis associated with herpes zoster ophthalmicus, and a 43-year-old gentleman with post-vaccination acute retinal necrosis were included. We present a possible link between anti-SARS-CoV-2 virus vaccination and varicella zoster reactivation in these patients and also describe the clinical features, imaging findings including confocal imaging, corneal nerve fiber analysis, and management with detailed discussion., Competing Interests: None

A 56-year-old man presented with right-sided headache and ptosis accompanied by a facial skin rash. He was diagnosed with herpes zoster ophthalmicus (HZO). Despite acyclovir and steroid therapy, the ocular symptoms worsened. Magnetic resonance imaging (MRI) revealed severe orbital inflammation and abnormal lesions in the right trigeminal nucleus and tract. The effects of re-administration of intravenous acyclovir and steroid pulse therapy were limited. Laser irradiation of the stellate ganglion (SGL) and high-dose oral prednisolone therapy were effective. Our experience suggests the efficacy of early multimodal treatment, including SGL, in treating ocular symptoms associated with HZO.

Background: Effective pain control of herpes zoster ophthalmicus (HZO) is not only essential to attenuate the clinical symptoms but to reduce the risk of postherpetic neuralgia development. Recently, neuromodulation therapy has been one promising option for neuropathic pain and increasingly applied in management of zoster-related pain. One key factor of neuromodulation treatment is the therapeutic site for the impaired nerves. In this study we aim to investigate one novel dual-neuromodulation strategy, targeting the level of the peripheral branch and trigeminal ganglion, in the pain management of HZO., Methods: Dual neuromodulation strategy combining short-term peripheral nerve stimulation (PNS) with pulsed radiofrequency (PRF) of trigeminal ganglion was compared with single PNS treatment for HZO-related pain. Clinical recordings of patients were retrospectively reviewed. The primary outcome was the pain severity, assessed by the visual analogue scale (VAS) before and after neuromodulation therapy., Results: PNS achieved significant relief of pain with or without PRF treatment before discharge, which provided enduring therapeutic effect up to 12-month follow-up. The mean reduction of VAS was 6.7 ± 1.4 in dual modulation therapy ( n  = 13) at last follow-up and 5.4 ± 1.5 in PNS subgroup ( n  = 20), respectively. Moreover, dual modulation strategy provided better control of pain compared with PNS therapy alone at each time point., Conclusion: It is feasible and effective to combine the PNS and PRF in pain management of HZO. This novel dual modulation strategy of trigeminal pathway may provide additional therapeutic effects of pain symptoms in HZO population.

Competing Interests: The authors declare no conflict of interest.

Objectives: The aims of this study were to describe the clinical presentation and treatment modalities of acute retinal necrosis (ARN) and to evaluate complications and clinical outcomes according to the extent of retinal involvement at initial presentation., Materials and Methods: The medical records of 52 patients diagnosed with ARN were reviewed and 48 were included in the study. Patients were categorized into two groups according to the extent of retinitis at presentation: retinal involvement of 1-2 quadrants (Group A) or 3-4 quadrants (Group B)., Results: The mean age of the 14 women and 34 men at presentation was 51.3±13.6 years (range: 27-78). There were 40 unilateral and 8 bilateral cases. There were 11 eyes (19.6%) in Group A and 45 eyes (80.4%) in Group B. Eleven patients (22.9%) had a history of herpes simplex virus/varicella-zoster virus infection. One patient in Group A and 11 patients in Group B had received local or systemic corticosteroid therapy without concomitant antiviral treatment before referral. The median follow-up period was 29 months (range: 1-209) in Group A and 8.5 months (range: 0.75-209) in Group B. Mean visual acuity (VA) at presentation was 0.42±0.55 LogMAR (range: 0-2.0) in Group A and 1.28±0.95 LogMAR (range: 0-2.9) in Group B (p<0.05). The presence of endothelial keratic precipitates at presentation was significantly different between two groups (p=0.021). Retinal detachment (RD) occurred in 1 eye (9.1%) in Group A and 30 eyes (66.7%) in Group B (p<0.001). Optic disc pallor was seen in 36.4% (4/11) of eyes in Group A and 71.1% (32/45) of eyes in Group B (p=0.033). Other ocular complications were not significantly different between two groups. Mean final visual acuity was 0.29±0.41 LogMAR in Group A and 1.61±0.90 LogMAR in Group B (p<0.05)., Conclusion: The extent of retinal involvement at presentation affects visual outcomes and this shows the importance of early diagnosis and early initiation of antiviral treatment., Competing Interests: Conflict of Interest: No conflict of interest was declared by the authors., (©Copyright 2022 by Turkish Ophthalmological Association | Turkish Journal of Ophthalmology, published by Galenos Publishing House.)

We present a case of herpes zoster ophthalmicus (HZO) with a rare complication of orbital apex syndrome (OAS) manifesting as optic perineuritis with multiple cranial nerve palsies. A 65-year-old with COPD presented to the hospital with a vesicular rash involving his left eyelid. He was admitted for HZO and a concurrent COPD exacerbation. The HZO was treated with antivirals and the COPD exacerbation was treated with corticosteroids. On hospital day three, he developed left-sided ptosis, ophthalmoplegia, and a mid-dilated fixed pupil. MRI of the brain demonstrated enhancement of the left optic nerve sheath, rectus muscles, and periorbital soft tissues. He was diagnosed with OAS and treated with an increased dose of corticosteroids. After two months, his orbital symptoms resolved. This case is unique because the patient developed HZO in the setting of corticosteroid treatment for a COPD exacerbation, and his HZO progressed to OAS despite proper initiation of antiviral therapy.

Objective: To investigate the anatomical, pathogenetic, and pharmacological characteristics of herpes zoster ophthalmicus (HZO)- related ophthalmoplegia., Methods: Case report-based systematic review was performed., Results: This study included 96 patients (54 [56.25%] women and 42 [43.75%] men [P = 0.221]). The mean age at presentation was 64.32 ± 17.48 years. All the patients included in the study had HZO- related ophthalmoplegia, with rash presenting as initial symptom in 87 (90.62%) cases, and diplopia in 9 (9.38%) cases. Thirty-seven (38.54%) patients achieved complete recovery, whereas 59 (61.46%) patients had permanent ophthalmoplegia. Females recovered in 26/54 cases and males in 11/42 cases (P = 0.028). Recovery rates after peroral versus intravenous antivirals (15/38 versus 19/46) and > 10 days versus ≤10 days antiviral treatment (22/54 versus 12/30) did not significantly differ ( P = 0.865 and P = 0.947, respectively). immunocompetent patients treated with corticosteroids had significantly better recovery rates compared to immunodeficient counterparts (17/34 [50.00%] and 5/22 [22.73%], respectively [ P = 0.041])., Conclusions: The outcome of HZO-related ophthalmoplegia is associated with gender, immune status, corticosteroid use, and time of antiviral treatment initiation., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Purpose: The aim of this study was to describe risk factors for neurotrophic keratopathy (NK) after herpes zoster ophthalmicus (HZO)., Methods: This study was a retrospective review of all patients seen at the Auckland District Health Board with HZO from 2006 through 2016. Cox proportional hazards analysis was performed to examine time to development of neurotrophic keratitis., Results: Eight hundred sixty-nine patients were included in the study with a median follow-up of 6.3 years (5504.4 patient-years). The median age was 65.5 years (interquartile range 52.9-75.4), and 456 subjects (52.5%) were male. NK developed in 58 patients (6.7%), with the highest hazard 1 to 2 years after onset of HZO. On univariate analysis, age, White ethnicity, best-corrected visual acuity (BCVA) at presentation, intraocular pressure, corneal involvement, uveitis, and number of recurrences were associated with increased risk of NK. On multivariate analysis, the following factors were significant: age (hazard ratio [HR] = 1.03; P = 0.021), White ethnicity (HR = 3.18; P = 0.015), BCVA (HR = 1.81; P = 0.026), uveitis (HR = 3.77; P = 0.001), and recurrence (HR = 1.34; P < 0.001). Vision loss (BCVA ≤6/15) was more frequent in subjects with NK (65.5% vs. 16.3%, P < 0.001)., Conclusions: NK is a relatively common and serious complication of HZO and occurs more frequently in older White individuals, those with poor visual acuity at presentation, and those with uveitis. Vision loss occurs in approximately two-thirds of patients., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to investigate the effect of therapy with peripheral nerve stimulation (PNS) and pulsed radiofrequency (PRF) combined or PNS and PRF separately in patients with herpes zoster ophthalmicus (HZO)., Materials and Methods: This cohort study included 106 cases of HZO. Three groups were identified according to the type of treatment received: combination therapy (PNS+PRF) (n=38), PRF (n=37), and PNS (n=31). The observations at 0, 1, 2, and 4 weeks; 3 and 6 months; and 1 and 2 years after the operation were analyzed. Observations at each follow-up included baseline characteristics, Numerical Rating Scale (NRS) and the Pittsburgh Sleep Quality Index (PSQI), concomitant pain medication usage, relapse rate, and adverse events., Results: The postoperative NRS of all 3 groups were significantly lower than preoperative scores. The PSQI of the 3 groups was significantly improved postoperatively, and the concomitant pain medication gradually decreased. Regarding long-term efficacy, the pain NRS and PSQI scores of the PNS+PRF and PNS groups were significantly lower than those of the PRF group ( P <0.05), and the relapse rate of the PRF group was higher than that of the PNS+PRF and PNS groups ( P <0.05). No significant difference was observed between the PNS+PRF and the PNS groups., Conclusion: Both PNS and PRF treatment of HZO can decrease the pain score, yielding no serious complications. The combination of PNS and PRF or PNS alone resulted in more significant pain relief than treatment with PRF alone. Thus, PNS therapy may be a better treatment option for HZO., Competing Interests: Supported by National Key Research and Development Program of China (2020YFC2008400; China; (2020YFC2008403; Henan, China); The Key Science and Technology Project of Henan (International Science and Technology Cooperation Field) (182102410014); Henan, China; The Medical Science and Technology Project of Henan (201602040 Henan, China). The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To examine risk factors associated with cerebrovascular accident (CVA) following herpes zoster ophthalmicus (HZO)., Design: Retrospective cohort study., Methods: Review of medical records of all patients with HZO seen at the department of Ophthalmology, Auckland District Health Board, New Zealand, between January 1, 2006, and December 31, 2016. The main outcome measure was cerebrovascular accident within 12 months of diagnosis., Results: A total of 869 patients diagnosed with HZO were included in the study. The median age at onset of HZO was 65.5 years (interquartile range [IQR] 52.9-75.4), and 52.5% (n=456) were male. Antiviral therapy was started in 765 participants (88.0%), not used in 95 (10.9%), and not documented in 9 participants (1.0%). Four hundred sixty-eight participants (54.9%) received prompt oral antiviral therapy (≤72 hours of rash onset). A CVA occurred in the 12 months following HZO in 14 patients (1.6%) and was most common in older patients, occurring in 2.5% aged ≥65 years, 0.7% aged 40-65 years, and 0.9% aged <40 years. Hazard of CVA was highest immediately following HZO, with median time to CVA of 2.3 months (IQR 0.8-5.9 months). Patients who received prompt acyclovir had a 76.2% lower hazard of CVA (0.9% vs 2.6%, P = .022) on multivariate analysis., Conclusions: Cerebrovascular accident occurs in a low proportion of individuals within 1 year following HZO. Antiviral treatment for HZO may reduce the risk of subsequent CVA when given within 72 hours of rash onset., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Cutaneous granulomatous dermatoses are uncommon sequelae of herpes zoster (HZ) infection that have been documented in the literature, with granulomatous vasculitis described in rare cases. Here, we report a patient with HZ ophthalmicus who developed edematous plaques with central scarring in a V1 dermatomal distribution with histopathological changes of a granulomatous dermatitis including features of granulomatous vasculitis. J Drugs Dermatol. 2022;21(10):1127-1128. oi:10.36849/JDD.6749.

Competing Interests: V. A. Blanco-Palmero has received speaking fees from Admiral. The remaining authors report no conflicts of interest.

Purpose: The purpose of this study was to report a case of acute exacerbation in varicella-zoster virus (VZV) keratitis after SARS-CoV-2 vaccination., Methods: An 87-year-old man, with a history of herpes zoster ophthalmicus 10 years ago, was referred for sudden visual impairment in his left eye that started 2 days after his second dose of SARS-CoV-2 mRNA vaccine BNT162b2., Results: At presentation, his visual acuity was hand motion. Slitlamp examination revealed diffuse corneal stromal edema and nasal stromal infiltration. After treatment for 2 weeks with oral valacyclovir and topical corticosteroids, the problematic lesion was recovered and his visual acuity was restored to 20/30., Conclusions: We believe that this is the first report of possible association between recurrence of VZV keratitis and SARS-CoV-2 vaccination. We believe that T-cell activation by the host response after vaccination may affect the recurrence of VZV keratitis. Physicians should be aware of the potential of recurrence of VZV keratitis associated with the SARS-CoV-2 messenger RNA vaccine., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The purpose of this study was to describe the rationale and design of the Zoster Eye Disease Study (ZEDS)., Methods: ZEDS is a National Eye Institute-supported randomized clinical trial designed to determine whether 1 year of suppressive valacyclovir in patients with herpes zoster ophthalmicus (HZO) reduces complications because there is currently no high-quality evidence to support its use. Eligible patients are 18 years and older, immunocompetent, have a history of a typical rash at disease onset, and have had a record of active epithelial or stromal keratitis or iritis within 1 year before enrollment. Exclusion criteria include estimated glomerular filtration rate less than 45 or pregnancy. The primary endpoint is the time to first occurrence of new or worsening dendriform epithelial keratitis, stromal keratitis without or with ulceration, endothelial keratitis, or iritis due to HZO during 12 months of study treatment requiring prespecified treatment changes. The study has 80% power to detect a 30% difference between treatment groups, with a 30% rate of endpoints by 1 year assumed among controls. Secondary and exploratory questions include whether there is a persistent treatment benefit during the 6 months after treatment, whether development of postherpetic neuralgia varies by treatment group, and whether vaccinations against herpes zoster affect study outcomes and coronavirus disease 19 status., Results: Over approximately 4 years, over 400 study participants have been enrolled., Conclusions: ZEDS aims to provide scientific evidence on whether suppressive valacyclovir treatment improves outcomes in HZO and should become the standard of care., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: This study aimed to describe the clinical features of patients with orbital apex syndrome (OAS) as a complication of herpes zoster ophthalmicus (HZO) and to identify factors associated with poor visual acuity outcomes., Methods: We performed a systematic review and retrospective analysis of the clinical characteristics and outcomes of patients with OAS secondary to HZO reported in the literature over 42 years (1978-2020)., Results: We analysed 21 cases, 20 of which were identified in the literature, together with our patient. Their median age was 65 years, with equal involvement in both sexes. The median onset of OAS due to HZO was 10 days (range 1-28 days). The median time of treatment initiation was five days (range 1-21 days). All patients presented with reduced visual acuity, complete ophthalmoplegia, and ptosis. Most patients (17/21, 80.95%) were treated with systemic antiviral and corticosteroid therapy. Three (3/21, 14.29%) patients were immunocompromised. Recovery for ophthalmoplegia (19/21, 90.48%) and ptosis (16/21, 76.19%) was good. Half of the patients (9/18, 50%) showed poor vision recovery. Starting treatment more than 72 h after HZO onset (p = 0.045) was more likely to cause poor vision recovery., Conclusion: OAS is a rare, serious, and potentially late complication of HZO and continued observation up to and perhaps beyond four weeks is justifiable, if not encouraged. Early initiation of treatment with systemic antiviral and/or corticosteroids within 72 h of onset of HZO appears beneficial for the recovery of visual acuity., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: To identify clinical factors associated with the early reduction of corneal sensitivity (CS) in patients with herpes zoster ophthalmicus (HZO)., Methods: Total 30 subjects were divided into two groups according to the occurrence of an early reduction of CS (group 1, normal CS; group 2, decreased CS). The demographics, ocular manifestations of HZO, and the ocular surface parameters were compared between two groups. Then, the relative risks of variables were analyzed to expect the early decrease of CS by HZO using logistic regression analysis., Results: Among total 30 subjects, the CS decreased in 10 subjects (3.2 ± 1.4 cm, group 2) and the other 20 subjects revealed normal CS (6.0 ± 0.0 cm, group 1). The age was higher in the group 2 (67.0 ± 16.6 years) than in group 1 (48.0 ± 17.6 years, p = 0.013), but sex and the comorbidity of diabetes mellitus was not difference between groups. The presence of corneal punctate epithelial erosions was a single factor among the ocular manifestations of HZO, which discriminated group 1 (5%) and group 2 (60%, p = 0.002). The ocular surface staining scores (i.e., National Eye Institute scores and Sjögren's International Collaborative Clinical Alliance ocular surface score) were higher in group 2 (p = 0.001 and p = 0.021, respectively) than in group 1. The existence of corneal punctate epithelial erosions revealed as a sole risk factor for the early reduction of CS (odds ratio = 33.085; p = 0.016)., Conclusions: It is necessary to pay attention to the possible occurrence of neurotrophic keratopathy especially in older patients with HZO showing an initial presence of corneal punctate epithelial erosions.

Herpes Zoster (HZ) is rare in childhood and is defined as the reactivation of the latent varicella-zoster virus in patients who have previously been infected with varicella. When the virus affects the ophthal mic nerve it is called herpes zoster ophthalmicus (HZO) and it can produce, among other symptoms, acute headache, so it must be considered as a differential diagnosis., Objective: To describe a clinical case of HZO in a pediatric patient and to recognize its clinical manifestations and their importance in the differential diagnosis of acute headache in children., Clinical Case: Immunocompetent 11-year- old girl, vaccinated according to the recommended immunization schedule, excluding chickenpox vaccine due to past infection, presented to the emergency department (ED) with a 5-day long uni lateral headache. After 36 hours of hospitalization, she presented vesicular cutaneous lesions in her forehead, left upper eyelid, and nose. Positive fluorescein stain dendritic corneal lesions were iden tified in the ophthalmic exam. Antiviral systemic and topic therapy were set, obtaining an initial good response, but later she presented complications such as postherpetic neuralgia one month after hospital discharge and several postherpetic neuralgia episodes despite treatment with gabapentin in addition to two herpes zoster ophthalmicus relapses with acute keratouveitis one year after the initial episode., Conclusion: It is essential to include HZO in the differential diagnosis of acute headache, especially when presented unilaterally and/or with ocular symptoms, regardless of the presence of cutaneous lesions, and even more so in patients with history of chickenpox infection. Those patients who were vaccinated against this disease in their childhood will benefit from at least partial protection against HZO.