Ocular Herpes Zoster Can Be Chronic and Recurrent

MedicalResearch.com Interview with:
Kimberly D Tran, MD
Bascom Palmer Eye Institute

MedicalResearch.com: What is the background and purpose for this study? 

Dr. Tran: Approximately 30% of the population will suffer from herpes zoster (also known as shingles) at some point in their lifetime, with an estimated 1 million cases in the U.S. each year (1).  The most common long term complication of  herpes zoster is postherpetic neuralgia (PHN), or persistent neuropathic pain lasting beyond three months after initial presentation of  herpes zoster. PHN can negatively affect quality of life to a degree similar to congestive heart failure, depression, acute myocardial infarction,diabetes.

Postherpetic neuralgia is a leading cause of suicide in patients over 70 with chronic pain.(3,4) Of all the cases of herpes zoster, an estimated 10-20% will have herpes zoster ophthalmicus (HZO), which is defined as shingles in the area of the face near the eye, and sometimes the eye itself becomes involved.  Approximately 50% of individuals with HZO will develop ocular complications without antiviral treatment, while antiviral induction within the first 72 hours of rash onset reduces this number to 20-30% (2). Randomized control trial has demonstrated the efficacy antiviral therapy in the treatment of herpes zoster on first presentation.(6) What is less understood is the course of HZ after its initial presentation. Traditionally studied and treated in the acute phase,(5-7) recent data suggest that some patients experience a chronic or recurrent disease course. Based on this data, it is clear that more information is needed on the long term clinical course of herpes zoster ophthalmicus. The purpose of this study was to characterize the epidemiology of recurrent and chronic HZO in a unique South Florida population, with an ethnically and racially mixed, predominately male population.

MedicalResearch.com: What are the main findings?

Dr. Tran: 90 patients with  herpes zoster ophthalmicus were included in the study. The mean age at incident episode of HZO was 68±13.8 years (range, 27–95 years). The majority of patients were white (73%), immune competent (79%), and did not receive zoster vaccination at any time point in their follow up (82%). Patients were followed from first episode of shingles for a mean of 3.9±5.9 years, (range, 0-33 years). The period prevalence of HZ in any dermatome was 1.1%, the frequency of  herpes zoster ophthalmicus was 0.07% and the frequency of HZO with eye involvement was 0.05%. The overall 1, 3, and 5-year recurrence rates for either recurrent eye disease or rash were 8%, 17%, 25%, respectively. Ocular hypertension and uveitis increased the risk of recurrent and chronic disease.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Tran: This study supports newer data that a significant proportion of patients experience recurrent and chronic herpes zoster ophthalmicus. As such, we need to rethink our current standardized antiviral treatment algorithms which do not address these aspects of HZO.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Dr. Tran: Further study is needed to evaluate the role of extended duration, prophylactic, and/or maintenance dose antiviral therapy in cases of recurrent and chronic HZO


Tran KD et al. Epidemiology of Herpes Zoster Ophthalmicus: Recurrence and Chronicity. Ophthalmology. Article in press April 2016. 


1) Harpaz R, Ortega-Sanchez IR, Seward JF, (CDC) ACoIPACfDCaP. Prevention 345 of herpes zoster: recommendations of the Advisory Committee on Immunization 346 Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30; quiz CE32-34.

2) Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS. A population based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82(11):1341-1349.

3) McElhaney JE. Herpes zoster: a common disease that can have a devastating impact on patients’ quality of life. Expert Rev Vaccines. 2010;9(3 Suppl):27-30.

4) Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology. 2008;115(2 Suppl):S3-12.

5) McKendrick MW, McGill JI, White JE, Wood MJ. Oral acyclovir in acute herpes 385 zoster. Br Med J (Clin Res Ed). 1986;293(6561):1529-1532.

6) Wood MJ, Johnson RW, McKendrick M 386 W, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. 1994;330(13):896-900.

7) Huff JC, Bean B, Balfour HH, et al. Therapy of herpes zoster with oral acyclovir. Am J Med. 1988;85(2A):84-89.

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Last Updated on April 13, 2016 by Marie Benz MD FAAD