Herpes Zoster Opthalmicus

A middle aged lady presented with a vesicular rash on her face that was seen to be involving the ophthalmic division of the trigeminal nerve.

The case was diagnosed as Herpes Zoster Opthalmicus

Case Discussion:
Reactivation of endogenous latent varicella-zoster virus within the trigeminal ganglion with neuronal spread through the ophthalmic branch results in crops of grouped vesicles on the forehead and periocularly.

Clinical features; Patients typically present with periocular rash and an injected eye, along with a watery discharge. The most common corneal lesion is punctate epithelial keratitis, in which
the cornea has a ground-glass appearance because of stromal edema. Pseudodendrites, also very common, form from mucous deposition, are usually peripheral, and stain moderate to poorly with fluorescein. These may be differentiated from the dendrites of herpes simplex in that the pseudodendrites lack the rounded terminal bulbs at the end of the branches, and are broader and more plaquelike. Anterior stromal infiltrates may be seen in the second or third week after the acute
infection. Follicles (hyperplastic lymphoid tissue that appears as gray or white lobular elevations, particularly in the inferior cul-de-sac) and regional adenopathy may or may not be present. Iritis is seen in approximately 40% of patients.

Herpes Zoster Ophthalmicus. A large circular dendrite is seen in this patient with ocular involvement from HZV

Management:

• Treat patients with epithelial defects with topical broad-spectrum antibiotics to prevent secondary infection. Initiate oral antivirals within 72 hours of onset, and treat for 7 to 10 days.
• Use cycloplegics if an iritis is present. 
• Artificial tears or ointment may be helpful and narcotic analgesics may be required.
• Ophthalmologic consultation is indicated.

Clinical Pearls
1. Ocular complications may follow the rash by many months to years. These complications have a highly variable presentation that can mimic almost any ophthalmic condition.
2. Recurrence is more common in the immunocompromised host.
3. Perform a careful eye exam with corneal staining. Nearly two-thirds of patients will develop ocular lesions.
4. Corneal hypesthesia and the appearance of dendrites with fluorescein staining are seen in both herpes zoster ophthalmicus and herpes simplex keratitis.
5. Patients with skin lesions on the tip of the nose (Hutchinson sign) are at high risk for ocular involvement. However, the eye may be involved without a nasal lesion.