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Herpes Zoster Post-herpetic Neuralgia:

68 year-old male with decreased vision

Jeffrey Maassen, MD, Thomas Oetting, MD

June 20, 2005

Chief Complaint: 68 year-old male with decreased vision, OD.

History of Present Illness: Patient has noticed a three day history of decreased visual acuity OD, right periorbital headache, and right periorbital rash.

Ocular History: No previous ocular history. No eye surgery, trauma, nor contact lens use.

Medical History: History of basal cell cancer of the nose. Review of systems was otherwise negative.

Medications: None

Family History: Noncontributory

Social History: Noncontributory

EXAM OCULAR

• Visual Acuity: OD-- 20/25; OS-- 20/20
• Extraocular motility: Full, OU
• Intraocular pressure (IOP): Normal, OU
• Pupils: 4 mm in dark. 3 mm in light, OU. No afferent pupillary defect (APD).
• Confrontation visual fields (CVF): Full, OU
• External and anterior segment examination: Cornea was clear with no dedritic nor pseudodentritic forms. There was no anterior chamber reaction/inflammation. External skin exam revealed crops of vessicular lesions in a V2 distribution. Several lesions on the right lower lid were causing lid edema and ectropion. (See Figure 1)

Figure 1

A: Crusted, vesicular lesions in the V2 distribution, limited to the right side/respecting the midline. Ectropion noted temporally secondary to edema/induration infraorbitally.	B: Crops of vessicular lesions in V2 distribution well delineated on upper lip and oropharynx.

Discussion:

Herpes zoster occurs after primary infection with the zoster virus. The virus lies dormant in sensory nerve ganglia until it reactivates in the distribution of the affected ganglia. This results in a dermatomal eruption of a vesicular rash. In ophthalmology, particular attention is paid to rule out involvement of the eye resulting in keratitis, iritis, or acute retinal necrosis. Ocular involvement is greatest with V1/ophthalmic branch involvement, but may be seen with V2 distribution as well. In this particular patient, there was no evidence of the corneal involvement nor intraocular inflammation that can sometimes be seen with herpes zoster.

Of interest in this patient is the presence of ectropion secondary to a significant amount of localized induration and edema. This was secondary to suspected bacterial cellulitis superimposed on the affected area, as can often occur with zoster skin lesions. There was initial concern that scarring of the cheek could have resulted in permanent ectropion. However, prompt treatment with ocular lubrication, oral acyclovir for the zoster, and oral cephalexin (Keflex®) for the cellulitis resulted in resolution without corneal damage nor permanent ectropion (Figure 2). In some patients, however, this can be a permanent result.

Figure 2

Same patient 1 week after treatment with acyclovir and cephalexin (Keflex). Note resolution of vesicles with remaining excoriated areas. Less ectropion is present, and this eventually resolved completely.

Course: The patient did have some persisting pain and parasthesias in the V2 distribution even after resolution of the skin lesions. This pain was controlled with oral gabapentin (Neurontin). In close follow-up, the cornea never showed signs of involvement.

Diagnosis: Herpes Zoster with ectropion

EPIDEMIOLOGY Very common - 10-20% of U.S. population Less likely in African-Americans Equal gender distribution Incidence increases with age, trauma, immune suppression

OCULAR SIGNS Vesicular dermatomal rash External ocular disease: Eyelid scarring, loss of cilia, cicatricial entropion or ectropion Hutchinson's sign (presence of vesicles on the tip, side, or root of the nose) indicates V1 distribution and is a strong predictor of ocular involvement (Leisegang, 2004) Ocular surface disease: Keratitis (may be interstitial, disciform, or mucous plaque keratitis) or scleritis Punctate or dendritic epithelial erosions [dendritic lesions are seen most often with simplex (HSV) infection but have been documented with zoster] Diminished corneal sensation Anterior uveitis, trabeculitis, and increased IOP Posterior ocular involvement: Focal choroiditis Retinal vasculitis Acute Retinal Necrosis (ARN) or Progressive Outer Retinal Necrosis (PORN) - (more likely in severely immunosuppressed individuals) Orbit Orbital occlusive arteritis: ptosis, orbital edema, proptosis Retrobulbar optic neuritis Cranial neuropathies

SYMPTOMS Prodrome of fever, increased sensation, malaise and headache Pain, burning sensation and increased sensation in the affected dermatome Ophthalmic symptoms include decreased vision, pain, and dysesthesia

TREATMENT (for isolated skin involvement) Antiviral therapy: Oral antiviral therapy (acyclovir, famciclovir, or valacyclovir) - IV for immune suppressed Shortens duration of viral shedding Reduces duration of pain, modest benefit for post-herpetic neuralgia Best if initiated within 72 hours, but some reports suggest benefit if started after 72 hours (Leisegang, 2004) Antivirals + Corticosteroids Acute phase pain reduction with steroids, increase in quality of life scores, cutaneous healing rate accelerated No difference in time to resolution No effect on post-herpetic neuralgia Increased risk of steroid-related complications Gabapentin: Decreased post-herpetic neuralgia compared to placebo Amitriptyline

Differential Diagnoses for Herpes Zoster

• Herpes simplex
• Coxsackie virus
• Variola virus