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Herpes zoster ophthalmicus (HZO) is a sight-threatening condition that is defined as HZ involving the ophthalmic division of the trigeminal nerve. Cases of bilateral HZO in recent literature question the notion of HZO being a strictly unilateral disease. Its pathogenesis is a topic of debate and current literature on VZV dissemination lacks insight into the underlying immunology. This review focuses on novel research in immunology of HZO and aims to formulate hypotheses of spread of lesions through the CNS. A literature search was conducted on Entrez PubMed using the search terms “bilateral” and “herpes zoster ophthalmicus”. Articles on (“Immunology” or “immune cells”) and “herpes zoster ophthalmicus” were also searched for. Articles published from January 1942 to April 2020 that were in English language were included. Our findings revealed that hypothesised mechanisms of dissemination causing bilateral ocular disease include transmission from nerves to vessel walls, the synergistic action of the immune and nervous systems through the action of substance P and the von Szily reaction. These mechanisms may be investigated using newer models of animal experimentation. It is imperative to define the molecular mechanisms behind VZV transmission to improve methods of identification, treatment, and prevention of HZO.

The Role of Nervous System and Immune System in Herpes Zoster Ophthalmicus Dissemination and Laterality – Current Views