Treatment of Opthalmic Branch Post-Herpetic Neuralgia with Blocks

I hate forehead/eye Post-herpetic Neuralgia. Upper facial Post herpetic Neuralgia has to be the worst case scenario. Local eye drop make a difference for eye. See:
Lidocaine Eye Drops For Ophthalmic Postherpetic Neuralgia
A case study highlights the benefits of nerve block to forehead in PHN

IASP Poster PH 358, Montreal 2010
A. M Rodrigues da Cunha1, C. HFukusima1, S. C da Silva Junior2, C. Rocha2, 1Anesthesia, Hosp. de Base, São josé do Rio Preto, Brazil, 2Neurosurgery, Hosp. de Base, São josé do Rio Preto, Brazil

  • 52 years old, 78 kg, married, diabetics, cardiac transplant at 4 years ago
  • Pain from PHN 10/10
  • Treatments:
     – 25 mg amitriptyline day,
    –  600 mg gabapentin day,
    –  every 4/4 hours 50 mg tramadol
    –  ophthalmic nerve anesthetic blockade
  • Subject had one block and was down to 3/10 when seen 1 month later – was given a second block and pain was gone.
  • Blocks:

The opthalmic division is covered by 2 nerves – Trochlear and Supraorbital:

  • Find supraorbitral notch top junction of outer 2/3 and inner 1/3 orbit
  • 25 gauge one inch needle inject
  • They used 4 ml of 0.25% bupivacaine without vasoconstriction
  • According to:
    Techniques of Regional Anaesthesia
    D. Bruce Scott
    Combined trochlear and supraorbital blocks can be obtained by injecting horizontally above the eyebrow. One would have to concentrate on getting from at least midline (for trochlear) to outer 1/3 of orbit (for supraorbital) – is simple enough. Some people are so tender in the face, that you might have to pre-treat with emla cream…

Comment – so for opthalmic division do above eyebrow blocks, for mid division do infraorbital blocks (definitely need emla pretreat)

for lower do mental blocks and intraoral air max blancas air max blancas

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3 Responses to Treatment of Opthalmic Branch Post-Herpetic Neuralgia with Blocks

  1. Clara says:

    My husband has been suffering with “Opthalmic Branch Post-Herpetic Neuralgia” for more than 4.5 years. The area describe here is exactly same as his PHN area.
    Currently he is taking 600mg Gabapentine 3 times a day and have tried numerous other pain killers or/and antidepressants and nothing helped.
    How can we contact with the doctor who can perform the nerve block described here?
    He is 62 years old, 165 lb., borderline diabetics, 1 stent from angioplasty, otherwise healthy male.
    We would be very grateful if you can send us the information regarding this treatment.

    Thank you very much in advance.


    It’s such a horrible problem, I’ve decided to write a new blog note about it here:
    Upper Facial Post Shingles Pains – Blocks
    Goopd luck

  2. Pingback: Upper Facial Post Shingles Pains – Blocks | Pain Medical Musing

  3. richard brook says:

    I have post herpetic neuralgia, mostly terrible itching on right side of scalp and over right eyebrow. Always hurts if I wrinkle my brow. Now about three months. Had three or four shingles lesions right forehead which cleared up in a week. Had the shingles vaccine in 2009. Now taking Neuronitin, 400mg day. Will likely go up, though worried about double vision which I had on Lyrica.

    Am interested in Ketamine/amitryptiline ointment; though my neurologist said he couldn’t prescribe it; moreover he worried about Serotonin syndrome since I also take Paxil 40mg daily.

    Any suggestions will be appreciated.

    There is a new form of capsaicin (red pepper) cream that has minimal eye irritation called Zuacta (zucapsaicin cream, 0.075% w/w) marketed in Canada by Sanofi-Aventis Canada Inc. and
    Distributed by Valeant Canada LP.
    Zuacta monogram here:

    They stated “An ocular irritation study was conducted in 3 male New Zealand White rabbits where 0.1 mL of 0.075% zucapsaicin was instilled into the right eye of each animal and irritation was scored up to 72 hours post-dose. Slight conjunctival redness was observed at 1 hour post-dose only and zucapsaicin was considered non-irritating.”

    These capsaicin creams, if used regularly help post zoster pains even around the eye:

    The use of capsaicin in herpes zoster ophthalmicus neuralgia
    Joseph Frucht-Pery, Sandy T. Feldman, Stuart I. Brown
    Acta Ophthalmologica Scandinavica Volume 75, Issue 3, pages 311–313, June 1997

    This above article was written before this less irritating formulation was made – but still, try not to rub in eye…
    Not sure how available it is in USA but imagine it is. This would be a good place to start…

    Capsaicin creams are used for itch – and is one of the few things found to help intractible anal itch:
    Gut. 2003 Sep;52(9):1323-6.
    Topical capsaicin–a novel and effective treatment for idiopathic intractable pruritus ani: a randomised, placebo controlled, crossover study.
    Lysy J, Sistiery-Ittah M, Israelit Y, Shmueli A, Strauss-Liviatan N, Mindrul V, Keret D, Goldin E.

    Drugs used for post herpetic itch include carbamazepine, gabapentin, and pregabalin combined with the antihistamine hydroxyzine:
    Post herpetic itching—A treatment dilemma
    Valentina Semionov, and Pesach Shvartzman
    Clin J Pain  Volume 24, Number 4, May 2008, 366-368 useless abstract here;

    5% Lidocaine patches are helpful but expensive unless you make your own:
    Make your own lidocaine patches:
    (note – need to dry them out until they are tacy)

    acupuncture may be helpful for facial post herpetic itch:
    Acupuncture treatment of facial postherpetic itch
    David Imrie, Andrew
    Physical Therapy Reviews, Volume 16, Number 2, April 2011 , pp. 133-137(5)
    – “The first treatment consisted of the following: LI4 bilaterally needled with even technique to a depth of 0.5 cun obtaining de qi, gall bladder (GB) 34 bilaterally needled with the same technique, ST40 ipsilaterally to the symptoms with thesame technique and ST44 ipsilaterally to the symptoms, but with reducing method. The author used 3060.25 mm Huanqiu needles for all points.”
    – “Four further treatments were given with a weekly frequency, using more local points pertaining [to the nerve distribution]” (i.e maxillary nerve distribution such as ST2, ST3, ST4,
    ST7, LI19, and LI20) – obviously more opthalmic ones for above eye distribution
    – started with 15 min insertions and worked up to 30 minutes.
    – had 20 treatments with 50% reduction in symptoms

    Good luck

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