Optic Neuritis Associated with Herpes Zoster Ophthalmicus: A Systematic Review and Analysis.

Purpose: To systematically review and analyze reported cases of herpes zoster ophthalmicus (HZO)-related optic neuritis (ON) without retinal involvement, a potentially sight-threatening complication of varicella-zoster virus (VZV).

Methods: A PRISMA-guided search of online databases from inception to January 31, 2025, identified case reports and series describing HZO-related ON without retinal involvement. Study quality was assessed using Joanna Briggs Institute checklists. Data on demographics, clinical features, diagnostics, treatments, and outcomes were analyzed using SPSS.

Results: Thirty-two studies (1919-2025) comprising 38 patients were included. The mean patient age was 52.6 years (ranging from 6 to 82), with a near-equal gender distribution. Comorbid conditions such as human immunodeficiency virus (HIV) infection, diabetes, and autoimmune disorders were noted in one-third of cases. ON most commonly presented unilaterally and ipsilateral to the dermatome of HZO. The mean interval from HZO onset to ON was approximately 22 days (ranging from 10 days prior to 150 days afterward). Blurred vision and eye pain were the most frequent symptoms. Common signs include visual field defect, congestion, mydriasis, and ophthalmoplegia. Keratitis was the most common observation in slit-lamp examination (62.8% (22 of 35 cases)). Corticosteroid therapy, including high-dose and pulse regimens, was administered in a third-fourth (28 of 38) of patients. In outcome assessment, 52.8% (19 of 36) achieved mild or no impairment, while 36.3% (12 of 36) experienced clinical blindness.

Conclusions: HZO-related ON is an uncommon but significant sight-threatening complication in HZO. Timely diagnosis and appropriate antiviral treatment along with corticosteroid therapy may improve the visual prognosis.