Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 3  |  Page : 289-291  

An interesting case of herpes zoster ophthalmicus


1 Department of Ophthalmology, Military Hospital Ahemdabad, Ahemdabad Cant, Hanuman Camp, Shahibag, Ahmedabad, Gujarat, India
2 Department of Ophthalmology, Command Hospital, Lucknow, Uttar Pradesh, India
3 Department of Ophthalmology, Military Hospital, Secunderabad, Andhra Pradesh, India
4 Department of Ophthalmology, Military Hospital, Jodhpur, Rajasthan, India

Date of Web Publication5-Jul-2013

Correspondence Address:
Avinash Mishra
Department of Ophthalmology, Military Hospital Ahmedabad, Ahmedabad Cant, Hanuman Camp, Shahibag, Ahmedabad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.114651

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  Abstract 

Approximately 20% of the world's population suffers from herpes zoster at least once in a lifetime, with about 10% to 20% of these having an ophthalmic involvement. Timely diagnosis of Herpes Zoster Ophthalmicus (HZO), with an early recognition of its various associated complications as well as their management along with an early referral to an ophthalmologist are critical in limiting visual disability. Here we report an interesting case of HZO in a young individual who in addition to the corneal involvement also had anterior uveitis as well as grossly raised intra ocular pressure

Keywords: Anterior uveitis, herpes zoster ophthalmicus in young, raised intraocular pressure


How to cite this article:
Mishra A, Baranwal VK, Patra VK, Srivastava VK. An interesting case of herpes zoster ophthalmicus. Med J DY Patil Univ 2013;6:289-91

How to cite this URL:
Mishra A, Baranwal VK, Patra VK, Srivastava VK. An interesting case of herpes zoster ophthalmicus. Med J DY Patil Univ [serial online] 2013 [cited 2021 Apr 19];6:289-91. Available from: https://www.mjdrdypu.org/text.asp?2013/6/3/289/114651


  Introduction Top


Herpes zoster ophthalmicus (HZO) is defined as herpes zoster (HZ) involvement of the ophthalmic division of the fifth cranial nerve. It is the second most common type of HZ, after thoracic zoster. [1]

HZ affects about 20% of the world's population at least once in their lifetime, with nearly 20% of these showing an ophthalmic involvement. [2]

Timely diagnosis of HZO, with an early recognition of its various associated complications as well as their management, along with an early referral to an ophthalmologist are all critical in limiting visual disability.


  Case Report Top


A 31-year-old male patient was transferred to this center from a peripheral hospital as a case of HZO (right eye). The patient gave a history of acute painful vesicular eruptions on the right side of his forehead. There was also involvement of the adjacent part of the face, extending up to the tip of the nose, of 2 weeks duration. Initially there had been no involvement of the eyes and so he was diagnosed as a case of HZ and managed with systemic antivirals (tab acyclovir 800 mg five times daily), ointment acyclovir 5%, as well as systemic steroids (tab prednisolone 30 mg daily). However, around the 10 th day, he developed redness, pain, and blurring of vision in his right eye. He was diagnosed as a case HZ, which had progressed to HZO (right eye) and the following was added to his treatment, i.e., eye ointment acyclovir 3% five times daily as well as topical cycloplegics. However, over the next 2 days, his condition worsened with the pain becoming very severe and he was transferred to this center. On arrival, his vision in the right eye was 2/60 and the intraocular pressure (IOP) was 56 mm of Hg, as measured with a non-contact tonometer (NCT). Slit-lamp examination revealed severe circumcorneal congestion, a very hazy cornea with stromal edema and Descemet's folds as well as scattered keratic precipitates (KPs) on the corneal endothelium. The anterior chamber (AC) had multiple cells (grade 3+) but no flare. The pupil was round and mid dilated (due to the cycloplegics eye drops) and non-reacting [Figure 1]. Fluorescein staining of the corneal epithelium was negative [Figure 2]. A diagnosis of stromal keratitis was made and he was immediately started on systemic and topical antiglaucoma drugs (i.e., tab acetazolamide 250 mg four times daily), timolol and dorzolamide eye drops, as well topical steroids, i.e., prednisolone acetate 1% eye drops. Topical antivirals as well as the cycloplegics were continued as before. The patient was also investigated for human immunodeficiency virus (HIV), but it was negative. Within 3 days, the patient claimed a substantial relief from pain and his vision improved to 6/60; however, the stromal folds, the cells (grade 2), and the KPs persisted [Figure 3]. A detailed fundoscopy done at this stage revealed a normal fundus. When the IOP reduced to 24 mm of NCT, tablet acetazolamide was tapered off. By the end of 2 weeks, only a few KPs remained. The pupil was dilated fully and there were no cells in the AC. The patient's vision improved to 6/12 and his IOP became normal, i.e., 14 mm of Hg NCT [Figure 4]. The antiglaucoma drugs were stopped; however, the topical steroids were continued over the next 2 weeks in tapering doses. The patient was finally discharged after 5 weeks with a vision of 6/6 and no residual complication whatsoever [Figure 5]. However, knowing the recurrent nature of keratouveitis, the patient is being regularly followed up on an outpatient basis, with advice to report immediately in case of any recurrence of symptoms.
Figure 1: On presentation - The cornea is hazy, KPs can be seen on the endothelium, and the pupil is mid-dilated

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Figure 2: A negative fluorescein stain

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Figure 3: Cornea is clearer

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Figure 4: Cornea clear; IOP normal; Vision improved to 6/12

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Figure 5: At the time of discharge: Vision 6/6

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  Discussion Top


HZ, also called shingles, occurs due to reactivation of varicella-zoster virus (VZV) or the human herpes virus 3 infections. Following the primary varicella (chickenpox) infection, the virus remains dormant in the dorsal root or other sensory ganglia. Reactivation usually occurs due to a decline in the specific cell-mediated immunity to VZV with aging, immunosuppression, or both. [1]

Ocular involvement occurs in about 50% of patients with HZO. [3] Ophthalmic complications include lid scarring, paralytic ptosis, conjunctivitis, neurotrophic keratitis, episcleritis, scleritis, iridocyclitis, choroiditis, acute retinal necrosis, glaucoma, ophthalmoplegia, and optic atrophy. Corneal involvement may present as punctate epithelial keratitis or disciform stromal keratitis. Herpetic uveitis commonly presents as unilateral anterior uveitis. [1]

Our patient had initially presented as a case of HZ and was started on oral as well as topical antivirals in high doses. [4] He was also given oral steroids in a tapering schedule, which when used along with systemic antiviral has been shown to statistically reduce acute pain and accelerate healing of cutaneous lesions. [5]

Subsequently, it progressed to involve the right eye and was treated with antiviral eye ointment. [4] However, he deteriorated with a fall in vision as well as increasing pain and was transferred to this center. Ocular examination on presentation revealed stromal keratitis associated with anterior uveitis and raised IOP, another vision-threatening complication of HZO. [6] He was successfully managed with antiglaucoma drugs as well as topical steroids [7] in tapering doses.

The incidence and severity of HZO increases with advancing age, and it is especially severe in those older than 60 years. [8] However, its occurrence at such a young age is often associated with an underlying HIV infection. [9] Rather the risk of HZ is at least 15 times greater in men with HIV than those without HIV and so all young individual with HZ should be investigated for HIV infection. [10]


  Conclusion Top


The management of HZ usually involves a multidisciplinary approach aiming to reduce complications and morbidity. The significance of this case is highlighted by the fact that in spite of delay in presentation as well as presence of such severe vision-threatening complications, the patient's eye could still be salvaged and he could be discharged with an absolutely normal vision.

The take-home message from this case is that it highlights the importance of an early referral of all patients with HZO to the nearest eye center. The treating doctors too should be aware of all its associated potential vision-threatening complications which if not promptly detected and adequately treated may even lead to a total loss of vision.

 
  References Top

1.Sanjay S, Huang P, Lavanya R. Herpes zoster ophthalmicus. Curr Treat Options Neurol 2011;13:79-91.  Back to cited text no. 1
    
2.Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology 2008;115 (2 Suppl):S13-20.  Back to cited text no. 2
    
3.Harding SP. Management of ophthalmic zoster. J Med Virol 1993;(Suppl 1):97-101.  Back to cited text no. 3
    
4.Severson EA, Baratz KH, Hodge DO, Burke JP. Herpes zoster ophthalmicus in Olmsted county, Minnesota: Have systemic antivirals made a difference? Arch Ophthalmol 2003;121:386-90.  Back to cited text no. 4
    
5.Whitley RJ, Weiss H, Gnann JW Jr, Tyring S, Mertz GJ, Pappas PG, et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial. The National Institute of allergy and infectious diseases collaborative antiviral study group. Ann Intern Med 1996;125:376-83.  Back to cited text no. 5
    
6.Wensing B, Relvas LM, Caspers LE, Valentincic NV, Stunf S, de Groot-Mijnes JD, et al. Comparison of rubella virus- and herpes virus-associated anterior uveitis: Clinical manifestations and visual prognosis. Ophthalmology 2011;118:1905-10.  Back to cited text no. 6
    
7.Dworkin RH, Johnson RW, Breuer J, Gnann JW, Levin MJ, Backonja M, et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007;44 Suppl 1:S1-26.  Back to cited text no. 7
    
8.Ghaznawi N, Virdi A, Dayan A, Hammersmith KM, Rapuano CJ, Laibson PR, et al. Herpes zoster ophthalmicus: Comparison of disease in patients 60 years and older versus younger than 60 years. Ophthalmology 2011;118:2242-50.  Back to cited text no. 8
    
9.Gupta N, Sachdev R, Sinha R, Titiyal JS, Tandon R. Herpes zoster ophthalmicus: Disease spectrum in young adults. Middle East Afr J Ophthalmol 2011;18:178-82.  Back to cited text no. 9
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10.Buchbinder SP, Katz MH, Hessol NA, Liu JY, O'Malley PM, Underwood R, et al. Herpes zoster and human immunodeficiency virus infection. J Infect Dis 1992;166:1153-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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