The ophthalmic nerve (V1) is the smallest and most superior division of the trigeminal nerve, arising from the trigeminal ganglion and passing through the cavernous sinus wall to enter the orbit through the superior orbital fissure. It divides into three branches: the frontal nerve (supraorbital and supratrochlear, forehead and scalp), the lacrimal nerve (lacrimal gland and lateral eyelid), and the nasociliary nerve (globe, cornea, nasal cavity). V1 is purely sensory.
The ophthalmic nerve and its branches are affected in herpes zoster ophthalmicus (V1 zoster), producing unilateral forehead, upper eyelid, and ocular surface vesicles with risk of keratitis, uveitis, and post-herpetic neuralgia. The Hutchinson sign (nasal tip involvement indicating nasociliary branch V1 involvement) predicts high risk of ocular complications. Cavernous sinus pathology (thrombosis, aneurysm, meningioma) produces V1 sensory loss as the nerve runs in the sinus lateral wall. Trigeminal neuralgia occasionally affects V1 distribution though V2 and V3 are more commonly involved.
Varicella-zoster virus reactivation in the trigeminal ganglion spreading along V1 produces unilateral forehead vesicular rash with eye pain, photophobia, and risk of corneal dendrites, stromal keratitis, and anterior uveitis; IV or oral antivirals within 72 hours reduce post-herpetic neuralgia risk and ophthalmic complications.
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