Hi,

My dad has been suffering from opthalmic post-herpetic neuralgia for
nearly five years.  I am posting here because I love him very much and
am desperate to find any help for him.  I will be extremely grateful
for any assistance you can provide and will add a generous tip for a
thorough answer.

My dad developed shingles on the first division of the trigeminal
nerve in February-March of 2001.  Since that time, he has been in
daily agony with horrible pain primarily in his eye and eyelid--but
also in his forehead and scalp.  After a number of failed medication
trials, he is currently taking 300 mg/day of Neurontin (I know the
dose is very small, but neurontin has caused severe somnolence for
him--so much so that it has led him to fall asleep at the dinner table
with food in his mouth) and 50 mg/day of maprotiline, along with other
medications for unrelated conditions.  I would be very grateful if you
could help with the following questions:

1) First, in light of my dad's demoralized state, I am searching for
reports of anyone who has had post-herpetic neuralgia for over two
years and has then recovered.  I would appreciate journal articles,
doctors' accounts, or first-person patient reports.

2) What are the newest treatment ideas for post-herpetic neuralgia?  I
am not interested in surgery or other invasive procedures.  I am
interested in traditional or non-traditional medication approaches.

3) Who are the leading researchers in the field of post-herpetic
neuralgia or, better yet, opthalmic post-herpetic neuralgia.

Thank you very much.  I shall be happy to provide any clarification
that would be of help.

                       -Calpurnia33

Hi calpurnia33-ga, and thanks for your interesting and difficult
question.  As you well know, post-herpetic neuralgia is a very serious
condition, probably comparable in debilitation to trigeminal neuralgia
and torticollis.  I will take your questions one-by-one, focusing on
newer treatment options, since you specify that your father has
already failed the traditional medical therapies and is already on
neurontin.  From your description, your father has involvment of the
first division of the trigeminal (cranial) nerve, sometimes referred
to as V1 (the 1st division of the 5th cranial nerve).  This disease
falls under the general category of neuropathic pain, similar to
trigeminal neuralgia.


=========
Recoveries
=========

There are some reliable stories of recoveries after prolonged
intractable postherpetic neuralgia (PHN). Here are some references:

Hoffmann V, Coppejans H, Vercauteren M, Adriaensen H.  Successful
treatment of postherpetic neuralgia with oral ketamine. Clin J Pain.
1994 Sep;10(3):240-2.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7833583&query_hl=2&itool=pubmed_docsum

The full text of this article is not available online, but you may be
able to find it at a local library.  Here are libraries that have this
article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=7833583&dopt=ExternalLink&ExternalLink=libs

______

Klepstad P, Borchgrevink PC.  Four years' treatment with ketamine and
a trial of dextromethorphan in a patient with severe post-herpetic
neuralgia.  Acta Anaesthesiol Scand. 1997 Mar;41(3):422-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9113190&query_hl=2&itool=pubmed_docsum

Again, the full text of this article is not available online, but you
may be able to find it at a local library.  Here are libraries that
have this article:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&list_uids=9113190&dopt=ExternalLink&ExternalLink=libs

You can also find a large number of first person stories at the facial
neuralgia support site:
http://facial-neuralgia.org/support/tnstory.html

This is a great resource for patients suffering from a variety of
difficult facial neuralgias, including PHN.

______


Here's another story from the Herpes support newsgroup:
http://groups.google.com/group/alt.support.herpes/browse_frm/thread/f75f24f0b8160ab0/369712173414f401?lnk=st&q=postherpetic+neuralgia+success&rnum=3&hl=en#369712173414f401

"From:		Chilipepper - view profile
Date:		Tues, Apr 27 1999 12:00 am
Not yet rated
 
I had these very same symptoms as dtwilken the first 2 years after my 
diagnosis.   There were times when the skin on the upper thigh and on 
the buttocks was  so sensitive that the material from clothing brushing 
against it hurt.  My right hip joint ached terribly and the pain shot 
down to the ankle and foot.  I never experienced any pain above the 
waist but have spoken to a woman in H-chat that has had that kind of 
pain with her genital herpes.   
Fortunately, as the years have gone by, 10 yrs now, the  neuralgia is 
not as painful.  I also was put on Valtrex for suppression and I'm 
pleased that it's working so well for me.  A decade is a long time to 
suffer. :( 

I  believe it's possible for the virus to be active all the time.  I 
know mine was! 

Will be interesting to hear what the neurologist has to say about 
Mindy's friend.  I hope she reports back and lets us know. "

______


Here's another from the fifty-plus newsgroup:
http://groups.google.com/group/alt.fifty-plus.friends/browse_frm/thread/c9085e7ade75bf83/af7058db3b38babc?lnk=st&q=postherpetic+neuralgia+success&rnum=12&hl=en#af7058db3b38babc

"From:		Yoj - view profile
Date:		Fri, Oct 27 2000 12:26 am
Not yet rated

It's good to see you back, Paul.  We have missed you.  I'm glad you had a 
good visit with your brother, and hope that your shingles or whatever the 
problem was has disappeared. 
I haven't been around much lately.  My mother has been with me for the past 
two weeks, and will be here another two weeks.  She had cataract surgery 
last week, and will have the other eye done next week.  In between, she 
visited a neurologist about her extremely painful postherpetic neuralgia. 
He recommended another doctor who has great success with bee venom therapy, 
and she had a treatment yesterday.  For about an hour after the treatment, 
she was in considerable pain, but since then she has had very little pain, 
and most of that wasn't until this evening.  She goes back tomorrow for a 
follow-up treatment tomorrow. 

Joy "

Here's a newsgroup search for 'postherpetic neuralgia success' that
you may find useful:
http://groups.google.com/groups?q=postherpetic+neuralgia+success&start=30&hl=en&



========
Treatment
========

Standard Therapy


Many treatment protocols include tricyclic antidepressants.  Aside
from the high rate of depression in people with PHN, the structure of
these medications is remarkably similar to other medications used for
chronic pain, such as Flexeril.  They actually differ by only a single
moiety (the central ring), suggesting that chronic pain and depression
are linked on more than a simple cause and effect level.  This is an
active area of current research.

Amytriptyline:
http://upload.wikimedia.org/wikipedia/en/8/80/AmitriptylineStructure.png

Flexeril:
http://www.medicinescomplete.com/mc/clarke/current/images/clk0442c001.gif

You can read more here if you're interested:
http://www.jr2.ox.ac.uk/bandolier/booth/painpag/Chronrev/antidc/antidep.html

______

You can feel the currently accepted treatment guidelines for PHN here,
from the Centers for Disease Control:
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5989&nbr=3947

A very useful and fairly complete overview of PHN can be found at eMedicine:
http://www.emedicine.com/neuro/topic317.htm

I highly recommend reading through the treatment regimens outlined in
the above two resources to determine if your father has tried all of
the currently accepted medications for this disorder.  Various types
of doctors treat PHN (neurologists, anesthesiologist pain specialists,
neurosurgeons, primary care doctors, etc.) and each has their own
preferred types of medications.

______

Latest Treatments
______


PHN is an area of intense research.  You can see the latest treatments
as they come through the pipeline by watching the news.  Here are some
Google News searches that you may want to set up an alert for:

http://news.google.com/news?client=safari&rls=en&ie=UTF-8&oe=UTF-8&tab=wn&q=postherpetic+neuralgia+treatment&btnG=Search+News

http://news.google.com/news?client=safari&rls=en&q=postherpetic%20neuralgia&ie=UTF-8&oe=UTF-8&sa=N&tab=wn

______

One drug just approved in the US and European Union is Lyrica from
Pfizer.  Here's an article describing it from the United Press:
http://www.upi.com/HealthBusiness/view.php?StoryID=20060127-115707-9371r

While this is primarily an anti-anxiety drug, it is also approved for PHN.

______

A current therapy for PHN is capsaicin, the "active" ingredient in
chile peppers.  An obvious advantage of the topical therapies is that
patients don't suffer from systemic side effects.  You can read more
here:
http://en.wikipedia.org/wiki/Capsaicin

Recently, a variant of this, NeurogesX (transacin, NGX-4010) has shown
some promise.  Here is an article describing it's current status:
http://www.pharmaceutical-business-review.com/article_news.asp?guid=75403947-45BC-4383-B7A2-EA2B8D46BF2E

______

There was hope at one point that epidural injections would help with
PHN, however, these have not been shown to be effective.  You can read
more here:
http://www.ivanhoe.com/channels/p_channelstory.cfm?storyid=12968

______

I have also searched through the current clinical trials and have
found a few of interest...

As mentioned above, NGX-4010 is a topical treatment.  You can find
information about the ongoing clinical trial here, including a list of
centers that are currently recruiting patients to try out this
treatment and their contact information:
http://www.clinicaltrials.gov/ct/show/NCT00115310?order=1

______

Another clinical trial is at an earlier stage of evaluation for MK0686
from Merck.  You can find information here:
http://www.clinicaltrials.gov/ct/show/NCT00282763?order=8

______

Merck is also performing a Phase II trial of MK-0759:
http://www.clinicaltrials.gov/ct/show/NCT00245544?order=7

______

Lamotrigene is being evaluated in patients with neuropathic facial
pain.  Here is the trial information:
http://www.clinicaltrials.gov/ct/show/NCT00243152?order=6

Their is a second lamotrigene trial focused more on trigeminal
neuralgia, for which your father might qualify, taking place at
Jefferson University in Philadelphia:
http://www.clinicaltrials.gov/ct/show/NCT00203229?order=5

______

Pfizer is testing another drug, Pregabalin, for patients with
peripheral neuralgias such as PHN:
http://www.clinicaltrials.gov/ct/show/NCT00219544?order=6
______

Your father may be a candidate for this trigeminal neuralgia trial of
baclofen (Gabapentin):
http://www.clinicaltrials.gov/ct/show/NCT00004431?order=2


Clinical trials are being initiated continuously, and it is worthwhile
to keep an eye on the current listings.  For neuralgia treatment
trials, you can check here:
http://www.clinicaltrials.gov/ct/screen/BrowseAny?path=%2Fbrowse%2Fby-condition%2Fhier%2FBC10.b%2FD009437%2BNeuralgia.k&recruiting=true

Here is another source of listings:
http://www.centerwatch.com/patient/studies/cat638.html
______

Another trial that has not yet opened involves the new drug
[S,S]-Reboxetine for PHN:
http://www.clinicaltrials.gov/ct/show/NCT00288652?order=4


=======

Another non-medical, but still noninvasive therapy that is currently
being investigated is transcranial magnetic stimulation (TMS). This is
an exciting area of research that is just starting to develop where
parts of the brain are focally stimulated using powerful magnets (not
the dubious "magnetic therapy" that is so popular in the press).   It
is currently being investigated as a potential therapy for chronic
pain, depression, etc.  This type of therapy is typically guided by
neurologists and neurosurgeons in a few centers around the world.  You
can read an exciting article here, from Assiut University Hospital in
Assiut, Egypt:

Khedr EM, Kotb H, Kamel NF, Ahmed MA, Sadek R, Rothwell JC. 
Longlasting antalgic effects of daily sessions of repetitive
transcranial magnetic stimulation in central and peripheral
neuropathic pain.  J Neurol Neurosurg Psychiatry. 2005
Jun;76(6):833-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15897507&dopt=Citation

This article is not available for free online, but you can request a
free reprint from Dr. Khedr:
Emankhedr99@yahoo.com

______

This somewhat older (2004) article is freely available online at the link below:

Lefaucheur JP, Drouot X, Menard-Lefaucheur I, Zerah F, Bendib B,
Cesaro P, Keravel Y, Nguyen JP.  Neurogenic pain relief by repetitive
transcranial magnetic cortical stimulation depends on the origin and
the site of pain.  J Neurol Neurosurg Psychiatry. 2004
Apr;75(4):612-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15026508&query_hl=13&itool=pubmed_docsum
http://jnnp.bmjjournals.com/cgi/content/full/75/4/612

There have been multiple other articles published on this topic, which
you can find here:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=15897507&tool=ExternalSearch

or here:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16174199

______

The following review article looked at TMS efficacy in various types
of chronic pain:

Pridmore S. Oberoi G. Marcolin M. George M. Transcranial magnetic
stimulation and chronic pain: current status.  Australasian
Psychiatry. 13(3):258-65, 2005 Sep.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16174199&query_hl=14&itool=pubmed_docsum

The above reference is not freely available online, however, you can
request a free reprint from Dr. Pridmore:
spridmore@iprimus.com.au

Table 2 of the above reference summarizes some results from studies of
TMS for pain, which you can see here:
http://img357.imageshack.us/img357/4933/snapshot200602111338286mk.jpg

Here is an example summary from one study:

"They then studied 60 patients with intractable unilateral neurogenic
pain to assess the analgesic effect of stimulation, and the influence
of pain origin and pain site on outcome.68 Ten hertz, 5 s, 20 trains,
80% MT or sham TMS was applied to M1 contralateral to the pain. Pain
was significantly reduced by active but not sham treatment. Pain
reduction of greater than 30% was achieved in 26.7% and pain was
unchanged or worsened in 35% of patients. Trigeminal nerve lesions and
facial pain were associated with the most favourable results. As to
the pain origin, poor results were achieved in brainstem stroke,
irrespective of the site of the pain."


Here are some excerpts of their summary discussion:

"Studies of TMS in chronic pain also have encouraging aspects.
Lefaucheur et al. found that a single-session 10 Hz TMS significantly
reduced chronic pain for up to 8 days.[63,66] Others also found pain
reduction, but this did not persist.[69,70] The study by Pleger et al.
is important because the patient group was homogeneous (CRPS).[71] A
single session of 10 Hz stimulation to M1 was used, and seven of 10
patients achieved pain reduction, but this persisted for only 90 min.

An important question yet to be decided is whether repeated sessions
will result in sustained pain relief. There is some evidence from
preclinical work that in healthy individuals, TMS may have cumulative
cortical excitability,[33,34] and major depressive disorder can be
successfully treated by serial TMS treatments.[53,56] Topper et al.
have published the only study of serial TMS sessions in chronic
pain.[58] They found no cumulative effects. However, only two patients
were examined, both suffering avulsion of the lower cervical roots,
and this does not exclude the possibility of other conditions
responding. Also, they applied TMS to the posterior parietal region,
which may not be the most appropriate target."

"The task is to properly evaluate the potential for TMS to provide
relief in chronic pain. If relief can be provided, even if temporary,
it will be a great boon. Maintenance treatment is common in medicine.
Maintenance TMS is already being provided for people with relapsing
major depression and may eventually have a place in the management of
chronic pain.[76]"

______

You can see an image of the magnetic cap and setup that's used here:
http://www.biomag.hus.fi/tms/

You may also be interested in this Wiki article:
http://en.wikipedia.org/wiki/Transcranial_magnetic_stimulation


The Medical University of South Carolina has an active research group
doing TMS and lots of resources to other sites.  See, for example,
these sites:

http://www.musc.edu/tmsmirror/WWWpages.html

Here's a (somewhat dated) list of centers around the world who work with TMS:
http://web.archive.org/web/20020208125702/http://www.ists.unibe.ch/ists/Centers.html

Here is a more complete list:
http://www.biomag.hus.fi/tms/groups.html

Here's the International Society for Transcranial Stimulation, which
is probably the place to look for the most complete, up to date
information on TMS:
http://www.ists.unibe.ch/

______


As one commenter noted, stereotactic radiosurgery is also used to
treat PHN.  There has been good success with this method.  Gamma Knife
is one type of stereotactic radiosurgery (X-Knife and CyberKnife are
others).  The following article describes its use in this regard:

Urgosik D. Vymazal J. Vladyka V. Liscak R. Treatment of postherpetic
trigeminal neuralgia with the gamma knife. [Journal Article] Journal
of Neurosurgery. 93 Suppl 3:165-8, 2000 Dec.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11143238&dopt=Abstract

Unfortunately, this article is not freely available online, but you
can request a free reprint from Dr. Urgosik:
urgo@zero.cz

Their study found that "[a] successful result (excellent, very good,
and good) was reached in seven (44%) patients and radiosurgery failed
in nine (56%). Pain relief occurred after a median interval of 1 month
(range 10 days-6 months). No radiation-related side effects have been
observed in these patients."


You can find a second more recent article here:


Keep MF. DeMare PA. Ashby LS. Gamma knife surgery for refractory
postherpetic trigeminal neuralgia: targeting in one session both the
retrogasserian trigeminal nerve and the centromedian nucleus of the
thalamus. [Case Reports. Journal Article] Journal of Neurosurgery. 102
Suppl:276-82, 2005 Jan.

You can request a free reprint from Dr. Keep:
mkeep@salud.unm.edu

or read a cached version here:
http://64.233.179.104/search?q=cache:gwvM2bhRerkJ:www.thejns-net.org/suppl/issues/v102ss/pdf/n1020276.pdf+mkeep%40salud.unm.edu&hl=en&gl=us&ct=clnk&cd=2


Here is a third recent article discussing the use of radiosurgery for
trigeminal neuralgia of unknown etiology:
Lim, M. et al. CyberKnife radiosurgery for idiopathic trigeminal
neuralgia. Neurosurg Focus 18 (5):E9, 2005.

Full text is here:
http://www.aans.org/education/journal/neurosurgical/may05/18-5-9.pdf

______

In terms of more invasive therapies, which I know you do not favor, I
recommend looking at the UCLA overview here:
http://neurosurgery.ucla.edu/Diagnoses/Pain/PainDis_3.html

and the Massachusetts General Hospital summary here:
http://shingles.mgh.harvard.edu/surgical.htm

==========
Researchers
==========

Many of the current researchers are listed in the clinical drug trials
and links above.  There is a lot of research being done on the
prevention of PHN, primarily focusing on vaccines.  Here are some of
the more important PHN researchers:

Dr. Anne Louise Oaklander, MD, PhD
Director, Nerve Injury Unit, Massachusetts General Hospital, Boston, Massachusetts
http://shingles.mgh.harvard.edu/alo_bio.htm

Dr. Anne A. Gershon, M.D.
Professor of Pediatrics and Director of Pediatric Infectious Diseases
Columbia University College of Physicians and Surgeons,
http://www.vzvfoundation.org/ScientificAchievementAward.html
http://www.columbiapresbyterian.com/dxprofile.asp?ID=704

Dr. Michael Rowbotham, M.D.
UCSF Department of Neurology
http://www.ucsfhealth.org/adult/cgi-bin/prd.cgi?action=DISPLAYDOCTOR&doctorid=1077


Dr. Stephen Tyring, MD, PhD
University of Texas
http://mmg.uth.tmc.edu/webpages/mmg%20program/MMG%20program%20faculty/styring.html


Dr. Michael Oxman
Depts. of Medicine and Pathology
UCSD
http://www.asci-jci.org/data/profile.php?pid=150250

Dr. Mitchell B. Max, M.D.
Clinical Trials Unit
NIH / National Institute of Dental and Craniofacial Research
http://www.nidcr.nih.gov/Research/Intramural/ClinicalTrials/MitchellMax.htm


There are, of course, many others. See for example this search on
Google Scholar on 'postherpetic neuralgia research'
http://scholar.google.com/scholar?q=postherpetic+neuralgia+research&hl=en&lr=&safe=off&client=safari&start=10&sa=N


Also, here's a recent article on vaccine research:
Oxman MN, et al.; Shingles Prevention Study Group.  A vaccine to
prevent herpes zoster and postherpetic neuralgia in older adults.  N
Engl J Med. 2005 Jun 2;352(22):2271-84.

http://content.nejm.org/cgi/content/abstract/352/22/2271

=============
Other Resources
=============

The Mayo Clinic PHN site:
http://www.mayoclinic.com/health/postherpetic-neuralgia/DS00277

The Massachusetts General Hospital shingles and PHN center:
http://shingles.mgh.harvard.edu/

Wikipedia:
http://en.wikipedia.org/wiki/Postherpetic_neuralgia

American Association of Family Physicians PHN overview
http://www.aafp.org/afp/20000415/2437.html

After Shingles PHN article
http://www.aftershingles.com/phn.html

A more in depth overview from US Pharmacist
http://www.uspharmacist.com/index.asp?show=article&page=8_957.htm

Article on facial neuralgias, with summary of treatments:
Ashkenazi A. Levin M. Three common neuralgias. How to manage
trigeminal, occipital, and postherpetic pain. [Review] [22 refs]
[Journal Article. Review] Postgraduate Medicine. 116(3):16-8, 21-4,
31-2 passim, 2004 Sep.

http://www.postgradmed.com/issues/2004/09_04/ashkenazi.htm


Another good overview of the efficacy of various treatments for PHN:
Hempenstall K, Nurmikko TJ, Johnson RW, A'Hern RP, Rice AS. Analgesic
therapy in postherpetic neuralgia: a quantitative systematic review.
PLoS Med. 2005 Jul;2(7):e164. Epub 2005 Jul 26.

Full text is here:
http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0020164

or here:
http://www.pubmedcentral.gov/articlerender.fcgi?tool=pubmed&pubmedid=16013891


Here's an article from the British Medical Journal outlining treatment
for patients with PHN who fail initial therapy:

Cunningham AL, Dworkin RH.	The management of post-herpetic neuralgia. 
BMJ. 2000 Sep 30;321(7264):778-9

Full text is here:
http://bmj.bmjjournals.com/cgi/content/full/321/7264/778
http://bmj.bmjjournals.com/cgi/reprint/321/7264/778

==============================================================

I hope this information is helpful.  I wish your father the best in
overcoming this devastating disease.  Please feel free to request any
clarification prior to rating.

Best,

       -welte-ga

---

Request for Answer Clarification by calpurnia33-ga on 24 Feb 2006 17:48 PST

Hi welte-ga,

My dad and I are very grateful for the thorough review that you
provided to us.  There is one potentially useful addition that you
could make to it and for which we would offer a $50 tip.  It has
seemed to us that ophthalmic shingles probably has some unique
features.  For example, I understand that there can be ophthalmic
after-effects of shingles and, obviously, some of the potentially
helpful treatments for PHN (e.g. lidocane patch) cannot even be used
on the eye.  My dad still has to keep his affected eye covered and, as
bad as the pain is on the forehead and scalp, the most excruciating
pain is, by far, eyelid and eye pain.  He also has vision compromised
by ptosis, the covering of the affected eye, and apparently some
sympathetic reactions by the unaffected eye.

Are you at all interested in searching out and writing up the
individual experiences, current thinking, and leading researchers in
the specific area of ophthalmic PHN?  Of course, I don't really know
whether there is much work available in addition to what you have
already posted.  If you are interested and provide a useful addendum,
I would be happy to add $50 to the sum that we have already paid to
you.

Thank you again for the very comprehensive review.

---

Clarification of Answer by welte-ga on 25 Feb 2006 09:03 PST

Hi again alpurnia33-ga,

I'd be happy to look more into ophthalmic PHN...  


First, you can find a fairly comprehensive article on herpes zoster
ophthalmicus below, which often results in the type of ocular PHN your
father has been experiencing.

http://scholar.google.com/scholar?hl=en&lr=&safe=off&q=cache:PeLHSfR4FX0J:www.compophupdate.com/Langston%2520for%2520website.pdf


One thing to consider is that while some of the topical medications I
mentioned such as lidocaine patches and capsaicin shouldn't be used on
the eye, they can be used on the skin within the same dermatome
(around the eye and forehead), which is thought by some to affect pain
within the distribution of the 5th Cranial Nerve and within the eye. 
The eye is often involved in herpes zoster infection via the
nasociliary nerve. See, for example, this article from Israel:

Frucht-Pery J, Feldman ST, Brown SI.  The use of capsaicin in herpes
zoster ophthalmicus neuralgia.
Acta Ophthalmol Scand. 1997 Jun;75(3):311-3. 

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9253983&query_hl=3&itool=pubmed_docsum

You can request a free reprint from Dr. Frucht-Pery:
fruchtpery@md.huji.ac.il
_______________

It would seem that topical anesthetics applied directly to the eye (as
eye drops) should provide some relief.  Unfortunately, the results
have been mixed with trials of such agents as Proparacaine drops. 
Here are some references to this type of treatment:

http://archfami.ama-assn.org/cgi/reprint/8/3/264.pdf
(see pages 266-267)

_______________

Another medication that might be an alternative to Neurontin is
pregabalin (related to Neurontin), which has shown promise in a study
published just this month:

van Seventer R, Feister HA, Young JP Jr, Stoker M, Versavel M, Rigaudy
L.  Efficacy and tolerability of twice-daily pregabalin for treating
pain and related sleep interference in postherpetic neuralgia: a
13-week, randomized trial. Curr Med Res Opin. 2006 Feb;22(2):375-84.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16466610&query_hl=7&itool=pubmed_docsum

You can request a free reprint from Dr. van Seventer:
7ster@planet.nl


[No authors listed]  Pregabalin: new drug. Very similar to gabapentin.
 Prescrire Int. 2005 Dec;14(80):203-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16397976&query_hl=7&itool=pubmed_docsum

"The few available treatments for neuropathic pain have limited
efficacy, and pregabalin may therefore be tried when both tricyclics
and gabapentin fail."

Pregabalin was just approved by the FDA for treatment of PHN:
http://www.medscape.com/viewarticle/497024?src=mp

_________

Another systemic medication, which I may not have mentioned, is slow
release oxycontin, which doesn't carry the risk of addiction and
doesn't give a "high" when taken.  See, for example, this article from
the University of Chicago:
http://www.journals.uchicago.edu/CID/journal/issues/v36n7/30307/30307.web.pdf

______

A search of the medical literature for postherpetic neuralgia and eye
diseases yields only 5 results, none of which are particularly
relevant or up to date:

1.
Margolis TP. Milner MS. Shama A. Hodge W. Seiff S. Herpes zoster
ophthalmicus in patients with human immunodeficiency virus infection.
[Journal Article] American Journal of Ophthalmology. 125(3):285-91,
1998 Mar.
UI: 9512144
2.
Gouda JJ. Brown JA. Atypical facial pain and other pain syndromes.
Differential diagnosis and treatment. [Review] [67 refs] [Journal
Article. Review] Neurosurgery Clinics of North America. 8(1):87-100,
1997 Jan.
UI: 9018709
3.
Harding SP. Lipton JR. Wells JC. Natural history of herpes zoster
ophthalmicus: predictors of postherpetic neuralgia and ocular
involvement. [Journal Article] British Journal of Ophthalmology.
71(5):353-8, 1987 May.
UI: 3495293
4.
Murray BJ. Medical complications of herpes zoster in immunocompetent
patients. [Journal Article] Postgraduate Medicine. 81(1):229-31, 233,
236, 1987 Jan.
UI: 3809038
5.
Ostler HB. Thygeson P. The ocular manifestations of herpes zoster,
varicella, infectious mononucleosis, and cytomegalovirus disease.
[Journal Article] Survey of Ophthalmology. 21(2):148-59, 1976 Sep-Oct.
UI: 185734

______

There are some additional articles available via Google Scholar, searching on 
postherpetic neuralgia (optic OR ophthalmic OR eye):
http://scholar.google.com/scholar?hl=en&lr=&safe=off&q=postherpetic+neuralgia+%28optic+OR+ophthalmic+OR+eye%29&btnG=Search

=============

Although there are few reliable stories of individuals who have
recovered from optic PHN, there have been some examples of relief of
ophthalmic pain in PHN using oral Ketamine:

Hoffmann V, Coppejans H, Vercauteren M, Adriaensen H. Successful
treatment of postherpetic neuralgia with oral ketamine. Clin J Pain.
1994 Sep;10(3):240-2.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7833583&dopt=Citation

Of course, there are likely many individuals who have recovered at
least partially from optic PHN, but have not publicly reported their
stories.


One place to look are the Usenet newsgroups.  Here's a sample search:

postherpetic neuralgia (ocular OR eye OR ophthalmic)
http://groups.google.com/groups?lr=&ie=UTF-8&q=postherpetic+neuralgia+%28ocular+OR+eye+OR+ophthalmic%29&qt_s=Search



=============
Below I have listed some additional resources dealing both with
ophthalmic PHN and PHN generally.



Pages 11-17 of this American Association of Family Practice article
give a nice summary on the traditional approach to postherpetic
neuralgia treatment:
http://www.aafp.org/PreBuilt/afpmonograph_shingles.pdf
______

You might also find this discussion of the evidence for various
treatments of postherpetic neuralgia and the related disorder
trigeminal neuralgia helpful:
http://www.clinicalevidence.com/ceweb/conditionpdf/0905.pdf
http://www.clinicalevidence.com/ceweb/conditionpdf/1207.pdf

Unfortunately, the two articles above are somewhat out of date.

______

You can also find a review of treatment options here:
http://www.treatment-options.com/article.cfm?Type=Article&PubID=NE03-5-1-01

______

A more up to date article from the British Medical Journal can be found here:
Johnson RW, Dworkin RH.  Treatment of herpes zoster and postherpetic
neuralgia.  BMJ. 2003 Apr 5;326(7392):748-50.

http://bmj.bmjjournals.com/cgi/reprint/326/7392/748

______

Stankus SJ, Dlugopolski M, Packer D.  Management of herpes zoster
(shingles) and postherpetic neuralgia.  Am Fam Physician. 2000 Apr
15;61(8):2437-44, 2447-8.

http://www.aafp.org/afp/20000415/2437.html

______

Mounsey AL, Matthew LG, Slawson DC.  Herpes zoster and postherpetic
neuralgia: prevention and management.  Am Fam Physician. 2005 Sep
15;72(6):1075-80.

http://www.aafp.org/afp/20050915/1075.html
______

Sra KK, Tyring SK.	Related Articles, Links
	Treatment of postherpetic neuralgia.
Skin Therapy Lett. 2004 Oct;9(8):1-4. 
http://www.skintherapyletter.com/2004/9.8/1.html

______

Although somewhat dated, here is another general article on PHN, from
the New England Journal of Medicine:
http://www.ecu.edu/intmedresidency/CurrentResidents/Review%20Articles/third%20collection/Postherpetic%20Neuralgia%20%97%20Pathogenesis,%20Treatment,%20and%20Prevention.pdf

______

Johnson RW.  Pain following herpes zoster: implications for
management.  Herpes. 2004 Dec;11(3):63-5.
http://www.ihmf.org/journal/download/113Johnson(63)vol1163.pdf
______

Johnson RW.  Herpes zoster in the immunocompetent patient: management
of post-herpetic neuralgia. Herpes. 2003 Aug;10(2):38-45.
http://www.ihmf.org/journal/download/102johnson(38)vol1038.pdf

========================================

I hope this is helpful.  Please feel free to request any clarification.

Best,

        -welte-ga

hi 
I am resident doctor in Neurosurgical Centre in VIMHANS, INDIA. I
would like to suggest you "GAMMA knife Readiosurgery". It is
noninvasive radiosurgey. Alternatively you can try Trigeminal Block
for pain releif...

Read an clinical tral case study.

Gamma knife surgery for refractory postherpetic trigeminal neuralgia:
targeting in one session both the retrogasserian trigeminal nerve and
the centromedian nucleus of the thalamus.

The authors tested the hypothesis that two targets are needed to treat
postherpetic trigeminal neuralgia (TN): one in the trigeminal nerve
for the direct sharp pain and one in the thalamus for the diffuse
burning pain. METHODS: Three patients with refractory postherpetic TN
were treated with gamma knife surgery (GKS) through a novel two-target
approach. In a single treatment session, both the trigeminal nerve and
centromedian nucleus were targeted. First, the trigeminal nerve,
ipsilateral to the facial pain, was treated with 60 to 80 Gy. Second,
the centromedian nucleus was localized using standard coordinates and
by comparing magnetic resonance images with a stereotactic atlas. A
single dose of 120 to 140 Gy was delivered to the target point with a
single 4-mm isocenter. Patients were followed clinically and with
neuroimaging
studies. Pain relief was scored as excellent (75-100%), good (50-75%),
poor (25-50%); or none (0-25%). Follow up ranged from 6 to 53 months.
There were no GKS-related complications. Two patients died of
unrelated medical illnesses but had good or excellent pain relief
until death. One patient continues to survive with 44 months follow up
and no decrease in pain intensity, but with a decreased area of pain.

CONCLUSIONS: Combined GKS of the centromedian nucleus and trigeminal nerve in a 
single treatment session is feasible and safe, and the effect was promising. 

Keep MF, DeMare PA, Ashby LS.

The Gamma Knife Center of the Pacific, Honolulu, Hawaii, USA.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15662825&dopt=Citation