Shingles Complications: Herpes Zoster Ophthalmicus and Ramsay Hunt Syndrome

Reactivation of varicella-zoster virus (VZV) can involve cranial nerves, leading to two serious, vision- and hearing-threatening complications.

Pathology: VZV reactivation in ophthalmic division (V1) of trigeminal nerve (CN V).
Key Sign: Hutchinson's sign – vesicles on tip/side of nose (nasociliary branch) → predicts ocular involvement (90% specificity).
Ocular Manifestations:
- Conjunctivitis, episcleritis, keratitis (stromal, neurotrophic), uveitis (iritis, chorioretinitis).
- Corneal ulceration → scarring, neovascularization, perforation, blindness.
- Elevated IOP (glaucoma), cataract, optic neuritis.
Management: Oral antivirals (valacyclovir 1g TID × 7d, famciclovir 500mg TID × 7d) within 72 hrs of rash onset. Topical antivirals (trifluridine) for keratitis. Cycloplegics, steroids (ophthalmologist only). Urgent ophthalmology referral.

Pathology: VZV reactivation in geniculate ganglion of facial nerve (CN VII) ± vestibulocochlear nerve (CN VIII).
Triad: Ipsilateral facial palsy (LMN type), vesicular rash in ear canal/concha/palate, vestibulocochlear symptoms.
Symptoms: Facial weakness/paralysis, otalgia, hearing loss, tinnitus, vertigo, nystagmus, taste loss (anterior 2/3 tongue), dry eye (reduced tearing).
Management: High-dose antivirals (valacyclovir 1g TID × 7d) + corticosteroids (prednisone 60–80 mg daily × 5–7d, taper) within 72 hrs improves facial recovery. Eye protection (lubricants, taping). Vestibular rehab for vertigo. Audiology follow-up.

HZO: 50% develop ocular complications; early treatment reduces severity. PHN common.
Ramsay Hunt: Complete facial recovery in ~70% with early combo therapy; hearing loss often permanent.

Recombinant zoster vaccine (RZV, Shingrix) 2 doses ≥50 years or ≥19 immunocompromised. Reduces HZO and Ramsay Hunt incidence by >90%.