07/06/2025
Case Summary: Acute Herpes Zoster Ophthalmicus in a 45-Year-Old Female
A 45-year-old woman presented to the casualty department with excruciating pain in the left eye, redness, and a painful boil-like lesion on the left forehead. The patient initially attributed her symptoms to an insect bite. On clinical examination, Dr. Thomas Koshy diagnosed her with Acute Herpes Zoster Ophthalmicus (HZO)—a reactivation of the varicella-zoster virus (VZV) affecting the ophthalmic branch (V1) of the trigeminal nerve.
Clinical Features:
The patient exhibited unilateral, dermatomal pain localized to the ophthalmic region, accompanied by a vesicular rash over the left forehead and around the eye. These symptoms are characteristic of HZO. Associated features included conjunctival injection, ocular discomfort, and photophobia, suggestive of ocular involvement. While the case summary did not mention Hutchinson’s sign (vesicles on the tip of the nose), it is clinically significant, as it suggests nasociliary nerve involvement and a higher risk of intraocular complications.
Herpes Zoster Ophthalmicus typically presents with a prodrome of pain or tingling, followed by vesicular eruptions in the distribution of the trigeminal nerve. Eye involvement may range from mild conjunctivitis to serious complications such as keratitis, uveitis, or optic neuritis.
Differential Diagnoses:
Several conditions may mimic HZO and must be considered:
• Insect bite reaction – Can cause local swelling and redness but lacks the dermatomal vesicular rash and neuropathic pain.
• Bacterial or viral conjunctivitis – Involves eye redness and discharge, usually bilateral and without facial rash.
• Preseptal or orbital cellulitis – Presents with eyelid swelling and erythema but lacks vesicles and dermatomal distribution.
• Trigeminal neuralgia – Presents with facial pain but does not involve a rash or vesicular lesions.
Treatment:
Dr. Koshy promptly initiated systemic antiviral therapy, the mainstay of HZO treatment:
• Oral Acyclovir 800 mg five times daily for 7–10 days, ideally started within 72 hours of symptom onset to limit viral replication and prevent complications.
• Topical antibiotic drops to prevent secondary bacterial infection.
• Lubricating eye drops for corneal protection.
• Analgesics, particularly NSAIDs, for symptomatic relief of pain.
Timely treatment led to significant improvement in the patient’s condition, with resolution of skin lesions and ocular symptoms within two weeks.
Complications:
Herpes Zoster Ophthalmicus can result in several complications if not treated early:
• Keratitis and corneal ulceration
• Anterior uveitis
• Secondary glaucoma
• Postherpetic neuralgia (PHN) – chronic pain persisting for weeks to months
• Permanent vision loss, especially with delayed treatment or recurrent infections
Management and Follow-Up:
Close ophthalmologic monitoring is essential for early detection and treatment of ocular complications. In cases of persistent neuropathic pain, medications such as gabapentin or amitriptyline may be needed. Preventive strategies include zoster vaccination in eligible older adults.
Conclusion:
This case highlights the critical importance of early recognition and prompt antiviral treatment in Herpes Zoster Ophthalmicus. Dr. Thomas Koshy’s timely intervention led to rapid recovery and prevention of serious complications. The case serves as a valuable learning point for clinicians in identifying and managing HZO effectively.
