Optic neuropathy and central retinal artery occlusion in a patient with herpes zoster ophthalmicus.

We present the case of a patient with herpes zoster ophthalmicus and optic neuropathy followed by central retinal artery occlusion. In those with herpes zoster ophthalmicus, in addition to the known usual complications, the possibility of this rare complication also should be considered, and the patient should be followed closely for a prolonged time.     

Isolation of the human T-cell leukemia/lymphotropic virus type III from aqueous humor in two patients with perivasculitis of the retinal vessels

Summary The human T-cell leukemia/lymphotropic virus type III (HTLV-III) has been isolated from aqueous humor in two patients with perivasculitis of the peripheral retinal vessels, an AIDS-related ocular manifestation. Both patients had antibodies to HTLV-III and although they presented with herpes zoster ophthalmicus, they did not present other symptoms known to be associated with HTLV-III infection. The isolation of HTLV-III from aqueous humor in these two patients with retinal perivasculitis suggests that the virus itself may play a role in the etiology of this ocular sign. The presence of infectious HTLV-III in the anterior chamber further emphasises the necessity to discard corneas from HTLV-III infected donors. Address for offprints: Mrs Suzy Sprecher-Goldberger, Institut Pasteur du Brabant, rue Engeland 642, Bruxelles/Uccle Belgium     

Herpes zoster ophthalmicus, contralateral hemiplegia, and recurrent ocular toxoplasmosis in a patient with acquired immune deficiency syndrome-related complex

A 42-year-old man presented with herpes zoster ophthalmicus on the right side. He was found to have acquired immune deficiency syndrome-related complex. Two weeks later he developed toxoplasmic retinochoroiditis in the left eye. He also presented later with left hemiplegia, which was probably caused by herpes zoster arteritis. Nine months after the retinal lesion resolved he developed another area of toxoplasmic retinochoroiditis adjacent to the first lesion. Herpes zoster may be the first presentation of acquired immune deficiency syndrome-related complex in a young healthy individual. Ophthalmologists are encountering patients with acquired immune deficiency syndrome who may have multiple organisms as the cause for their ocular infections and this might pose a treatment dilemma. The combination of herpes zoster ophthalmicus and ocular toxoplasmosis in this patient makes this case unusual.     

Optic neuropathy and central retinal artery occlusion in a case of herpes zoster ophthalmicus

In this case report the authors present a patient in whom loss of vision developed in the left eye in the early stage of herpes zoster ophthalmicus. He suffered from optic neuropathy followed by central retinal artery occlusion. Ophthalmologists should be aware of this rare and early complication of herpes zoster.     

Herpes Zoster Ophthalmicus Related Orbital Inflammatory Syndrome

We present two cases of herpes zoster related orbital inflammatory syndrome that preceded the development of the cutaneous vesicular eruption. These cases demonstrate that patients with presumed idiopathic orbital inflammatory syndrome should be warned about the development of herpes zoster and should be specifically evaluated for the cutaneous vesicular eruption of herpes zoster ophthalmicus and antiviral treatment initiated, if indicated.     

Ocular findings in Japanese patients with varicella-zoster virus infection

PURPOSE: To examine ocular findings in Japanese patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis. METHODS: A retrospective study was conducted. Information on the ocular, cutaneous, systemic, and virologic findings on pediatric and adult patients was obtained from medical records. RESULTS: A total of 77 (45 male and 32 female) patients were enrolled in the study: 4 children had varicella, 68 adults had herpes zoster ophthalmicus, and 5 adults had acute retinal necrosis. Children with varicella had eruptions on the eyelid. Patients with herpes zoster ophthalmicus had eruptions, conjunctivitis, keratitis, iridocyclitis, and other findings. Patients with acute retinal necrosis had intracameral cells and retinal lesions. Some patients with herpes zoster ophthalmicus had malignancy, type 2 diabetes mellitus, or other disease. One pregnant woman developed acute retinal necrosis shortly after varicella infection. A total of 48% of patients with negative Hutchinson sign had ocular lesions, while all patients with positive sign showed ocular lesions. Patients with varicella and herpes zoster ophthalmicus had good visual acuity at the last visit. Some patients with acute retinal necrosis had poor visual acuity at the last visit. CONCLUSIONS: Patients with varicella, herpes zoster ophthalmicus, and acute retinal necrosis had several ocular complications. Some patients with acute retinal necrosis had poor visual outcomes. Ophthalmologists should be aware that acute retinal necrosis may develop shortly after varicella infection.     

Herpes zoster ophthalmicus complicated by ipsilateral isolated Bell's palsy: a case report and review of the literature

The objective of this study was to present a unique case of unilateral facial nerve palsy as an isolated complication of herpes zoster ophthalmicus. An 82-year-old immunocompetent male presented with a 1-week history of painful left scalp lesions. The diagnosis of left herpes zoster ophthalmicus with associated keratoconjunctivitis was established. A 7-day course of oral acyclovir (800 mg/day) along with topical prednisolone acetate 1% and moxifloxacin were started. Three weeks later, the ocular zoster involvement resolved and the vesicular lesions of the skin had regressed. However, the patient developed an isolated left Bell's palsy that gradually improved with conservative therapy. To the best of our knowledge, we present an unusual case of herpes zoster ophthalmicus complicated by an isolated ipsilateral Bell's palsy. The patient has had a near complete resolution of all symptoms after antiviral therapy for the zoster ophthalmicus component along with conservative management for the Bell's palsy.     

Acute retinal necrosis following contralateral herpes zoster ophthalmicus

BACKGROUND: A case report of contralateral acute retinal necrosis (ARN) following herpes zoster ophthalmicus. CASE: A 61-year-old male patient developed iridocyclitis and well-demarcated creamy-white retinal lesions at the nasal periphery in the right eye 1 month after herpes zoster ophthalmicus in the left eye. The patient had undergone surgery for primary lung cancer, and had subsequent intracranial metastasis of the tumor. OBSERVATIONS: The clinical diagnosis of ARN was supported by polymerase chain reaction investigation of the aqueous humor resulting in positive for varicella-zoster virus. Retinal lesions disappeared after systemic treatment with acyclovir, corticosteroids, and acetylsalicylate. No retinal detachment developed. CONCLUSIONS: We propose a careful ophthalmic follow-up for herpes zoster ophthalmicus patients because of the possibility of acute retinal necrosis developing in the contralateral eye.     

Herpes zoster ophthalmicus: presenting as giant-cell arteritis

A 74-year-old woman was referred to the authors' clinic with a 1-week suspicion of giant-cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant-cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3-5 days.     

Herpes zoster vasculitis presenting as giant cell arteritis with bilateral internuclear ophthalmoplegia

PURPOSE: To present a case of herpes zoster vasculitis presenting as giant cell arteritis. DESIGN: Interventional case report. METHODS: A 77-year-old woman presented with sudden onset of diplopia associated with temple headaches and a previous history of herpes zoster ophthalmicus. A temporal artery biopsy was obtained and in-situ hybridization performed for herpes zoster DNA. RESULTS: The patient presented with a bilateral internuclear ophthalmoplegia. Initial diagnostic evaluation, including erythrocyte sedimentation rate, C-reactive protein, and temporal artery biopsy, was consistent with giant cell arteritis. However, in-situ hybridization of the temporal artery specimen was positive for herpes zoster DNA. CONCLUSIONS: Herpes zoster vasculitis may mimic giant cell arteritis and should be considered in the differential of any patient with presumed giant cell arteritis with suspicious findings, central nervous system involvement, or previous herpes zoster infection.     

Case of herpes zoster ophthalmicus with abducent palsy: the cause and magnetic resonance imaging findings

PURPOSE: To report the cause and magnetic resonance imaging (MRI) findings in a case of abducent palsy following herpes zoster ophthalmicus. CASE: A 76-year-old man presented with acute onset of pain, a vesicular cutaneous eruption and herpes zoster ophthalmicus on the right side. He developed complete abducent palsy on the right side two weeks after onset. MRI with gadolinium enhancement showed Meckel's sinus, which contains the trigeminal ganglion, and the abducent nerve on the right side. The patient was treated with intravenous acyclovir and methylprednisolone. The abnormal enhancement shown on MRI vanished immediately and the ophthalmoplegia resolved significantly. CONCLUSION: This is the first reported case where an affected cranial nerve was detected next to the inflammatory cavernous sinus in ophthalmoplegia following herpes zoster ophthalmicus. These MRI findings showed that this ophthlamoplegia was induced by direct viral invasion or extension of inflammation to the ipsilateral cranial nerve. Further studies need to be performed to clarify the role of specific antiviral therapy or anti-inflammatory agents in treating this complication of herpes zoster.     

Herpes Zoster Ophthalmicus in an Otherwise-Healthy Child

Herpes zoster ophthalmicus, although not uncommon in adults, is rarely found in children. Herein we present a case of pediatric herpes zoster ophthalmicus that is unique in 2 ways. First, the child had been vaccinated against varicella and otherwise had no known exposure to varicella-zoster virus. Second, the initial presentation of herpes zoster ophthalmicus was a painful and diffuse subconjunctival hemorrhage that appeared before any of its classic signs were observed. We report this case to document the possible occurrence of herpes zoster ophthalmicus in children who have been vaccinated against varicella and the possibility of a diffuse, painful subconjunctival hemorrhage as a presenting sign.     

Prognostic value of Hutchinson's sign in acute herpes zoster ophthalmicus

PURPOSE: To determine the prognostic value of nasociliary skin lesions (Hutchinson's sign) for ocular inflammation and corneal sensory denervation in acute herpes zoster ophthalmicus. METHODS: A longitudinal observational study with a 2-month follow-up was performed involving 83 non-immunocompromised adults with acute herpes zoster ophthalmicus, with a skin rash duration of less than 7 days, referred by their general practitioner. All skin lesions at the tip, the side and the root of the nose, representing the dermatomes of the external nasal and infratrochlear branches of the nasociliary nerve, were documented by taking photographs and marking anatomical drawings. Ocular inflammatory signs were observed by slit-lamp biomicroscopy, and corneal sensitivity was measured with the Cochet-Bonnet esthesiometer at 2-month follow-up. RESULTS: Hutchinson's sign was a powerful predictor of ocular inflammation and corneal denervation in herpes zoster ophthalmicus [relative risks: 3.35 (CI 95%: 1.82-6.15) and 4.02 (CI 95%:1.55-10.42), respectively]. The manifestation of herpes zoster skin lesions at the dermatomes of both nasociliary branches was invariably associated with the development of ocular inflammation. CONCLUSION: Clinicians should be alert for early skin lesions within the complete nasociliary dermatome, because they are a reliable prognostic sign of sight-threatening ocular complications in acute herpes zoster ophthalmicus.     

Observations on the natural history of herpes zoster ophthalmicus

We have studied certain aspects of the natural history of acute herpes zoster ophthalmicus in placebo-treated patients followed prospectively over one year as part of a therapeutic drug trial. Observations on the incidence of ocular complications relating to the efficacy of oral acyclovir in this disease have been previously published. This report provides supplemental observations on the natural history of frequently observed ocular complications of zoster ophthalmicus: corneal hypesthesia, episcleritis, dendritiform keratopathy, stromal keratitis, anterior uveitis, and post herpetic neuralgia. These ocular complications of zoster typically present within the first two weeks of the diagnosis. This report characterizes the onset of corneal hypesthesia, episcleritis, dendritiform keratopathy, stromal keratitis, and anterior uveitis as well as interrelationships amongst these sequellae of herpes zoster ophthalmicus. Post-herpetic neuralgia occurs in 52% of patients and persists beyond a year in 22% of those affected.     

A case of complete ophthalmoplegia in herpes zoster ophthalmicus

PURPOSE: To report a case with complete ophthalmoplegia after herpes zoster ophthalmicus. METHODS: A 70-year-old male patient visited a clinic because of vesicular eruptions over the left side of his face with severe pain. Drooping and severe swelling of the left eyelid were present, along with keratitis and uveitis. While the lid swelling and uveitis were improving, external ophthalmoplegia and exophthalmos were discovered. Intramuscular injections of dexamethasone 5 mg were given for 10 days, followed by oral administration of prednisolone at a dosage of 15 mg for two weeks and 10 mg for two weeks. RESULTS: The patient was fully recovered from the complete ophthalmoplegia and exophthalmos six months after the onset of the cutaneous lesion. CONCLUSIONS: Complete ophthalmoplegia is a rare ophthalmic complication of herpes zoster infection. Therefore, an evaluation of extraocular muscle and lid function should be performed during the examination of herpes zoster patients in order to screen for ophthalmoplegia.     

Penetrating keratoplasty for corneal scarring due to herpes zoster ophthalmicus.

We retrospectively studied the postoperative results in nine patients with corneal scarring due to herpes zoster ophthalmicus who underwent penetrating keratoplasty. This was a highly selected group that satisfied all of the following criteria: (a) absence of active disease of the ocular surface and eyelids, (b) intraocular pressure under control, and (c) absence of active keratouveitis. Penetrating keratoplasty after herpes zoster ophthalmicus may do well in patients with long preoperative quiescent periods in whom these restrictive preoperative criteria are observed.     

Acute phthisis bulbi and external ophthalmoplegia in herpes zoster ophthalmicus

A patient developed acute phthisis bulbi and external ophthalmoplegia with herpes zoster ophthalmicus (HZO). The clinical course and ocular complications of HZO are described briefly and the cause of phthisis bulbi and external ophthalmoplegia in zoster ophthalmicus is discussed. It is suggested that the acute hypotonia in HZO is due to an ischemic necrosis of the ciliary body, resulting from an occlusive vasculitis which may also be responsible for the external ophthalmolplegia.     

Herpes zoster ophthalmicus: a medical review.

Patients with herpes zoster undergo extensive screening to detect underlying malignant disease which is compromising their immunity. In a retrospective survey of 1000 patients with herpes zoster ophthalmicus 12 patients had malignant disease which was known on presentation. No new cases were detected or discovered on follow-up. Three patients developed a disseminated rash, but none of these had an underlying malignant disease.     

Herpes zoster ophthalmoplegia. Report of six cases

Ophthalmoplegia occurs infrequently in herpes zoster ophthalmicus. The third nerve appears to be the most commonly affected and the fourth nerve the least. We describe herein the clinical course of six patients with herpes zoster ophthalmoplegia. Spontaneous recovery occurred in four patients. The pathogenesis and clinical features of this syndrome are described.     

An unusual presentation of herpes zoster ophthalmicus: orbital myositis preceding vesicular eruption

PURPOSE: To present a case of orbital myositis associated with herpes zoster ophthalmicus. DESIGN: Observational case report. METHODS: A 47-year-old woman with acute retrobulbar eye pain and diplopia preceding the vesicular rash of herpes zoster ophthalmicus was evaluated and treated. RESULTS: Magnetic resonance imaging showed enlargement and enhancement of extraocular muscles consistent with an inflammatory myopathy. Following acyclovir and prednisone treatment, all symptoms resolved, and neuralgia did not develop. CONCLUSIONS: Herpes zoster may cause symptoms and signs of orbital myositis before eruption of cutaneous skin lesions and thus should be considered in the differential diagnosis of an acute orbital myositis.