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Photophobia and a painful rash
Correspondence to: A Malem email@example.com
A 62 year old woman presented to eye casualty with a 10 day history of a left sided headache. Two days after her headache started she developed a painful and pruritic left sided rash. During the 24 hours before presentation, her left eye had become injected, painful, and photophobic.
On examination she had a well demarcated, unilateral area of erythematous and mildly oedematous skin, which extended from her left upper lid up across her forehead. Within this area were discrete tender scabbed lesions, which extended back into her hairline. She had no lesions on the tip of her nose or in her auditory canal. No lesions crossed the midline to the right side of her forehead or scalp.
Fig 1 Left side scabbed skin lesions respecting the midline with associated left lid swelling and conjunctival injection
Ocular examination showed an unaided visual acuity of 6/6 in the right eye and 6/9 in the left eye. Ocular motility was full. Intraocular pressures were 10 mm Hg in the right eye and 12 mm Hg in the left. Her left cornea was clear and did not stain with fluorescein, while her conjunctiva was diffusely injected. Slit lamp examination of her left anterior chamber showed 1+ for cells and flare. Dilated funduscopy showed a clear vitreous and healthy fundus. Her right ocular examination was normal.
1. What is the most likely diagnosis?
Left herpes zoster ophthalmicus (HZO) with associated anterior uveitis.
2. How is the diagnosis confirmed?
The diagnosis of HZO is based on a history of varicella zoster virus (VZV) infection and the presence of a characteristic painful dermatomal rash. Further diagnostic tests are not usually needed. If the diagnosis is in doubt, polymerase chain reaction (PCR) on vesicular fluid for VZV DNA is the most sensitive and specific test.
3. How is the condition managed?
Uncomplicated HZO is managed with oral antivirals (aciclovir, valaciclovir, or famciclovir) and analgesia. Ophthalmic involvement warrants specialist ophthalmology review and management within 24 hours. Immunocompromised patients or those with severe systemic VZV infections may require hospital admission for intravenous antiviral treatment, supportive therapy, and monitoring.
4. What complications might occur?
Local ocular complications of HZO include conjunctivitis, keratitis, corneal scarring, uveitis, vitritis, retinitis, retinal necrosis, scleritis, optic neuritis, cranial neuropathies, eyelid cicatrisation, trabeculitis with raised intraocular pressure, cataract, and orbital apex syndrome. Complications from disseminated disease can involve neurological (encephalitis, neuritis, myelitis), respiratory (pneumonia), hepatic (hepatitis), and gastrointestinal (oesophagitis, gastritis, colitis) systems.
Our patient was prescribed a seven day course of aciclovir 800 mg five times a day and paracetamol and ibuprofen analgesia as needed. The anterior uveitis in her left eye was treated with a five week course of a reducing dose of topical dexamethasone 0.1%. At review one week later her ocular symptoms had resolved, with her vision improving to 6/6 in the left eye. At this time her rash and neuralgia were improving. At final review (six weeks later), after finishing all treatment, there were no remaining cutaneous lesions, although she reported residual numbness on her forehead. Her ocular examination was normal.
Patient consent obtained.
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