Case Study: It’s Not So Simple

YouningZhang Randleman
Presenter: Youning Zhang, MD Discussant: J. Bradley Randleman, MD
 

History

  • 80-year-old female
  • 10/10 pain and worsening blurry vision in left eye for two weeks
  • Denies exposure to swimming pools, hot tubs, lakes, trauma, foreign body or contact lens wear
  • Seen three months ago for similar complaints found to have dendrites in left eye concerning for HSV, was treated with acyclovir and steroids with mild improvement

Exam Findings

  • VA: 20/50, HM
  • Pupils equal round and reactive, no RAPD
  • IOP: 11,13
  • EOM: full OU
  • SLE OS: linear branching dendritiform lesion with raised borders extending across entire surface of cornea with weak fluorescein staining
Figure 1 and 2
Figure 1: Linear branching dendritiform lesion with raised border extending across the entire surface of the cornea.

 

Figure 1 and 2
Figure 2: Linear branching dendritiform lesion with raised border extending across the entire surface of the cornea.

 

Differential Diagnosis

  • Herpes simplex keratitis
  • Herpes zoster ophthalmicus
  • Recurrent corneal erosion
  • Acanthamoeba keratitis

Additional Investigations

  • HSV/VZV PCR negative
  • Wound culture negative

Diagnosis

  • Herpes Zoster Ophthalmicus

Pathophysiology

  • Reactivation of latent varicella zoster virus
  • Associated with aging, impaired immunity, trauma, psychological stress

Treatment

  • Topical steroids
  • Oral acyclovir

Prognosis and Future Directions

  • Herpes zoster ophthalmicus may be preceded by headache, fever, skin vesicles in a dermatomal distribution. Patients often complain of severe eye pain. It’s critical to distinguish HZO from other disease entities based on appearance alone as often times there is no skin findings and DNA PCR may be negative. HZO, when involving the epithelium, is an inflammatory process rather than an infectious one; therefore, the dendritiform lesions are not true ulcers and appear as elevated and not excavated. As such the mainstay of treatment is topical steroids and not topical antivirals which may prevent epithelium healing.

References

  • Cohen, EJ. Management and Prevent of Herpes Zoster Ocular Disease. Cornea 2015;34 (Suppl):S3-S8.
  • Colin J, Prisant O, Cochener B. Comparison of the efficacy and safety of valaciclovir and acyclovir for the treatment of herpes zoster ophthalmicus. Ophthalmology. 2000 Aug;107(8):1507-11
  • Edell AR. Cohen EJ. Herpes simplex and herpes zoster eye disease: presentation and management at a city hospital for the underserved in the United States. Eye Contact Lens. 2013 Jul;39(4):311-4.
  • Jensen H. Thomsen ST. Hansen SS, et al. Superior Orbital Fissure Syndrome and Ophthalmoplegia Caused by Varicella Zoster Virus with No Skin Eruption in a Patient Treated with Tumor Necrosis Alpha Inhibitor. Case Rep Neurol. 2015 Oct 30;7(3):221-6
  • Marsh RJ, Cooper M. Ophthalmic Herpes Zoster. Eye (1993) 7, 350-370
  • Marsh RJ, Cooper M. Double masked trial of topical acyclovir and steroids in the treatment of herpes zoster ocular inflammation. British Journal of Ophthalmology, 1991, 75, 542-546
  • Schaftenaar E, Peters RPH, Baarsma GS, et al. Clinical and corneal microbial profile of infections keratitis in a high HIV prevalence setting in rural South Africa. Eur J Clin Microbiol Infect Dis (2016) 35:1403-1409
  • Szeto SK, Chan TC, Wong RL, et al. Prevalence of ocular manifestations and visual outcomes in patients with herpes zoster ophthalmicus. Cornea. 2017 Mar: 36(3):338-342
  • Kalogeropoulos CD, Bassukas ID, Moschos MM, et al. Eye an d periocular skin involvement in herpes zoster infection. Med Hypothesis Discov Innov Ophthalmol. 2015;4(4).

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Produced by: Monica Chavez, John Daniel, Mellissa Linton and Dr. Vivek Patel