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A 44-year-old HIV-positive Hispanic man presented with painful herpes zoster of his right forehead (Figure 125-1). He was particularly worried because his right eye was red, painful, and very sensitive to light (Figure 125-2). On physical examination there was significant conjunctival injection, corneal punctate epithelial erosions, and clouding, and a small layer of blood in the anterior chamber (hyphema). The pupil was somewhat irregular. Along with the hyphema and ciliary flush, this indicated an anterior uveitis. The patient had a unilateral ptosis on the right side with limitations in elevation, depression, and adduction of the eye secondary to cranial nerve III palsy from the zoster. The patient was immediately referred to ophthalmology and the anterior uveitis, corneal involvement, and cranial nerve III palsy were confirmed. The ophthalmologist started the patient on topical ophthalmic preparations of erythromycin, moxifloxacin, prednisolone, and atropine. Oral acyclovir was also prescribed. Unfortunately, the patient did not return for follow up until 6 months later when he returned to the ophthalmologist with significant corneal scarring (Figure 125-3). The patient is currently on a waiting list for a corneal transplantation.

Figure 125-1

A 44-year-old HIV-positive Hispanic man with painful herpes zoster of his right forehead.

Figure 125-2

Acute zoster ophthalmicus of the same patient with conjunctival injection, corneal punctation (keratitis), and a small layer of blood in the anterior chamber (hyphema). A diagnosis of anterior uveitis was suspected based on the irregularly shaped pupil, the hyphema, and ciliary flush. A slit-lamp examination confirmed the anterior uveitis (iritis).

Figure 125-3

Corneal scarring and conjunctival injection of the same patient 6 months later after being lost to follow up.

Herpes zoster is a common infection caused by varicella-zoster virus, the same virus that causes chickenpox. Reactivation of the latent virus in neurosensory ganglia produces the characteristic manifestations of herpes zoster (shingles). Herpes zoster outbreaks may be precipitated by aging, poor nutrition, immunocompromised status, physical or emotional stress, and excessive fatigue. Although zoster most commonly involves the thoracic and lumbar dermatomes, reactivation of the latent virus in the trigeminal ganglia may result in herpes zoster ophthalmicus (HZO) (Figures 125-1, 125-2, 125-3, 125-4, 125-5, 125-6).

Figure 125-4

This 5-year-old girl had herpes zoster involving the ophthalmic branch of the trigeminal nerve. Note the vesicles and bullae on the forehead and eyelid and the crust on the nasal tip (Hutchinson sign). Fortunately, she did not have ocular complications and her case of zoster fully healed with oral acyclovir and acyclovir eye ointment. (Courtesy of Amor Khachemoune, MD.)

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