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Although a shingles rash that involves the tip of the nose (Hutchinson’s sign) is said to predict the development of herpes zoster ophthalmicus, one-third of patients without the sign have ocular complications.7 Involvement of other cranial nerves such as II (optic neuritis), III, IV and VI (diplopia) may suggest central nervous system involvement and patients require neurological as well as ophthalmological assessment. Conjunctivitis and mild to moderate non-specific keratitis are common acute presentations, with sight-threatening corneal stromal or intraocular inflammation more likely to occur one to two weeks after the onset of vesicular rash.Patients with suspected herpes zoster ophthalmicus should be started on oral acyclovir if they have presented within 72 hours of the onset of vesicular rash.7 Patients with decreased visual acuity and/or corneal epithelial defect on fluorescein examination should be referred for same-day ophthalmological assessment.BPJ Issue 54 17Dry-eye syndromeKeratoconjunctivitis sicca, known as dry-eye syndrome, occurs when there is deficiency or dysfunction of the tear film that normally keeps the eyes moist and lubricated.18 It is more common in females and incidence increases with age.18 Decreased tear production is most often age-related, but can also be due to systemic auto-immune diseases (e.g. Sjogren’s syndrome) or some medicines. Tear film dysfunction is often caused by blepharitis, altered lid position (e.g. ectropion), decreased blink rate (e.g. intense concentration, Parkinson’s disease), incomplete lid closure, or environmental factors.18Symptoms include a feeling of dryness, grittiness or mild pain in both eyes, which worsens throughout the day. Eyes water, especially when exposed to the wind.18 Patients are often aware that blinking or rubbing the eyes relieves symptoms. Conjunctival injection is usually mild, and fluorescein staining typically shows punctate epithelial erosions, which occur due to desiccation on the lower part of the cornea where lid coverage is least. The erosions are very small and may not be seen without magnification.Treatment includes eyelid hygiene (see: “Blepharitis”, Page 20), the use of artificial tears and managing exacerbating factors, e.g. limiting use of contact lenses, avoiding smoking, taking frequent breaks when concentrating on a screen.18 In some cases, punctal plugs are inserted into the lower or upper tear drainage canals of the eye, to reduce dryness.Complications of dry-eye syndrome include conjunctivitis and keratitis.18 BPJ Issue 54are persistent despite chloramphenicol treatment.11 If gonococcal conjunctivitis is suspected in an adult, collect an eye swab* (before applying any topical treatment) and test for gonorrhoea and chlamydia.14Newborn infants: If conjunctivitis is present in a newborn infant (aged ≤ 28 days), consider Chlamydia trachomatis or Neisseria gonorrhoeae as the cause, usually transmitted vaginally during birth.
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