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| CASE REPORT |
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| Year : 2013 | Volume
: 6
| Issue : 4 | Page : 450-451 |
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Herpes zoster maxillaris following cataract surgery
Medha Rajyan, Radhakrishnan Ozhukil Kolaph, Sadananda Patra, Akash Shah
Department of Ophthalmology, Padmashree Dr D Y Patil Medical College, Hospital and Research Centre, Dr D Y Patil Vidyapeeth, Pimpri, Pune, India
| Date of Web Publication | 17-Sep-2013 |
Correspondence Address:
Medha Rajyan
Dr. D. Y. Patil Medical College and Hospital, Pune-411 018, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0975-2870.118284
Herpes zoster maxillaries following cataract surgery is rare. We report here a case of a 70-year-old male who presented with vesiculo-papulo-macular rashes with hyperpigmented crusts over right malar prominence of cheek, side, and tip of the nose and upper lip, 3 days after undergoing uneventful cataract surgery of the right eye. He was treated with systemic acyclovir with resolution of skin lesions. Keywords: Cataract surgery, herpes zoster maxillaris, vesiculo-papulo-macular eruptions
How to cite this article:
Rajyan M, Kolaph RO, Patra S, Shah A. Herpes zoster maxillaris following cataract surgery. Med J DY Patil Univ 2013;6:450-1 |
| Introduction | |  |
Human herpes viruses are an important cause of ocular morbidity. Herpes zoster is a DNA virus that predominantly affects old people. [1] Children present with chicken pox occurring due to inhalation of viral particles. The virus remains in a dormant state in the trigeminal ganglia for years, getting reactivated in the elderly due to declining immunity. [2] Herpes zoster probably results from a failure of immune system in containing latent varicella-zoster virus replication. The ophthalmic division of the trigeminal nerve is 20 times more commonly involved than the maxillary or mandibular nerves. [3] A rare case of herpes zoster maxillaris 3 days after cataract surgery is reported.
| Case Report | | |
A 70-year-old male presented with complaints of vesiculo-maculo-papular eruptions over the right cheek, side, and tip of the nose and upper lip, 3 days after undergoing uneventful cataract surgery of the right eye. It was preceeded by mild fever, malaise, and piercing pain over the right cheek. The patient gave a history of chickenpox in childhood. There was no history of any other systemic illness.
Examination revealed multiple vesiculo-papulo-macular eruptions over the malar prominence of right cheek, side, and tip of the nose and upper lip [Figure 1].
His visual acuity in the right eye was 20/80, improving to 20/40 with correction. Lower lid oedema and ciliary congestion was present. Cornea was clear and corneal sensations were normal. Grade 1 cells and flare were present in the anterior chamber. The eye was pseudophakic [Figure 2]. Fundus was normal and intraocular pressure was 14.6 mmHg. Evaluation of the left eye revealed best corrected visual acuity of 20/60. Apart from lens showing cataractous changes, evaluation of the left eye was normal. Blood sugar profile was within normal limits. Serological tests for HIV were negative. X-ray of the chest was normal. A clinical diagnosis of herpes zoster maxillaris was made based on the typical sharp limitation of vesicular eruptions with a specific area of neural distribution. | Figure 1: Multiple vesiculo- papulo- macular eruptions over the malar prominence of right cheek, side and tip of nose & upper lip
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The patient was treated with oral acyclovir 800 mg (5 times a day for 7 days), tablet nortryptyline 25 mg (at bedtime), and application of lactocalamine lotion to the skin lesions. Topical treatment with tapering doses of prednisolone over 6 weeks and topical moxifloxacin (4 times a day for 2 weeks) were given for the right eye. The patient responded to the treatment, and, after 6 weeks of follow-up, the rashes disappeared and lid oedema subsided. The cornea was clear with the best corrected visual acuity improving to 20/30.
| Discussion | | |
Herpes zoster ophthalmicus is an ocular disease usually manifesting with unilateral painful skin rash in the dermatomal distribution of trigeminal nerve. It typically occurs in older adults, but can present at any age. It occurs due to the reactivation of latent varicella-zoster virus, which is present in the sensory cerebral ganglia. [4] The virus resides in the trigeminal ganglia and, when reactivated, spreads along the sensory nerve to the specific area of distribution of its three branches. Aging process and other causes of depressed immune response enhances the risk of developing zoster. Factors related to the development of zoster in patients are AIDS, iatrogenic immunosupression of organ transplant patients, neoplasia, blood dyscrasia, emotional or physical trauma, debilitating systemic disease of any type, surgery, and trauma to the involved ganglion. [5]
Incidence of herpes zoster after cataract surgery is rare. The rashes in our patient appeared only in the area of distribution of the maxillary nerve sparing the ophthalmic nerve area. Of the three branches of the trigeminal nerve, the maxillary nerve is least frequently affected branch. [3] It is very unusual for zoster to involve maxillary or mandibular without ophthalmic division, but occasional reports have appeared describing zoster affecting these branches and sparing the ophthalmic division. [1],[6] Zoster ophthalmicus may occur without skin rashes (zoster sine herpete). [5] In the present case, the maxillary involvement might have also preceded an ophthalmic zoster that was in zoster sine herpete form. There are established rami communications between nasal branches of maxillary with external nasal branches of the anterior ethmoidal branch of nasociliary (ophthalmic nerve). [7] These neuronal connections may explain tip of the nose involvement. Possibility of cataract surgery precipitating herpes zoster maxillaries could explain its occurrence immediately after cataract surgery.
| References | | |
| 1. | Jain S, Rathore MK. Maxillary zoster with corneal involvement. Indian J Ophthalmol 2004;52:323-4. 
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| 2. | Chern KC, Hwang DG. Herpetic uveitis. In: Yanoff M, Duker JS, editors. Ophthalmology. Philadelphia: Mosby; 1999. p. 10.
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| 3. | Tandon MP, Verma SK. Herpes zoster maxillaries: A case report. Indian J Ophthalmol 1987;35:160-1.
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| 4. | Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology 2008;115(Suppl 2):S3-12.
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| 5. | Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. Vol. 2., 2 nd ed. Philadelphia: W. B. Saunders; 2000. p. 864-9.
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| 6. | Jarrett WH. Horner's syndrome with geniculate zoster occuring in association with trigeminal herpes in which the ophthalmic division was spared. Am J Ophthalmol 1967;63:326-30.
[PUBMED] |
| 7. | Berry MM, Standring SM, Bannister LH. Nervous system-cranial nerves. In: Gray's Anatomy. 38 th ed. London: Churchill Livingstone; 1995. p. 1233-5.
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[Figure 1], [Figure 2]
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