The document describes a case of herpes zoster ophthalmicus in a 35-year-old man who presented with fever, forehead and eye pain, vesicles around the eye, and decreased vision in the left eye. It provides details on the presentation, diagnosis, treatment, and complications of herpes zoster ophthalmicus, which is caused by reactivation of the varicella zoster virus and results in shingles affecting the trigeminal nerve.

2. DEPARTMENT OF OPHTHALMOLOGY
SINDH GOVT. QATAR HOSPITAL
DR MARIAM KASHIF
POST GRADUATE STUDENT(MCPS)
DR JAMEEL AHMED BURNEY
SUPERVISOR/HEAD OF DEPARTMENT

3. Case
A 35 year old man presented with
 Fever - 4days
 Burning sensation on forehead
and around left eye - 2 days
 Vesicular eruptions - 1 day
 Discharge (LE) - 1 day
 DV (LE) - 1 day

4. History
 Low grade fever 4 days back associated
with headache, tiredness and malaise.
 Pain and Burning sensation on left side of
forehead and around left eye.
 1 day back eruption of groups of vesicles
on left side of forehead, left upper eyelid
and nose associated with itching and pain.
 Redness and mucopurulent discharge
from left eye along with decreased vision.

5. Past History
 No long term illness, decreased appetite
or weight loss.
 No drug history or known drug allergies.
 H/O chicken pox at the age of 10yrs.

6. Family and Social History
 Unmarried, lives with parents and two
siblings; all healthy.
 No addictions.
 Works in garment factory.
 Belongs to middle class family.

7. Medical Exam
 Well oriented young man, in pain and
concerned about his condition.
 Vitals: Blood pressure 120/70mmhg, pulse
80/min,temp 98 degree.
 CV: regular without murmur or gallop.
 Chest: clear.
 Abdomen: no significant finding.

8. Ocular Exam
 Visual Acuity 6/6 RE 6/12 LE
 External Inspection :erythamatous skin, groups
of flesh colored vesicles on left side of forehead,
left upper eyelid, along lid margin, side and tip of
the nose. (Hutchinson's Sign)
 Bilateral Ocular Motility normal
 Pupillary reactions normal

9. Slit Lamp Examination
RIGHT EYE LEFT EYE
Conjunctiva Normal Hyperemia
Cornea Clear Ulcer (Dendritic in
Sensation pattern
normal Fluorescine +ve)
Sensation reduced
Anterior Normal Normal
chamber
Lens Clear Clear
Fundus Normal Normal

10. Differential Diagnosis
OCULAR SKIN
Herpes simplex keratitis Drug allergy
Herpes zoster ophthalmicus Contact dermatitis
Insect bite

11. Diagnosis
HERPES ZOSTER OPHTHALMICUS
 History
 Vesicles (Hutchinson’s Sign)
 Dendritic ulcer

12. Varicella zoster virus
 Double stranded DNA virus
 Alphaherpesvirinae

13. Overview
VARICELLA ZOSTER VIRUS
Chicken pox dorsal root ganglia reactivation shingles
single dermatome

14. Risk Factors
 90% susceptible after primary infection
 Old age
 Immunosupression
 Malignancy
 Severe illness

15. Herpes Zoster Ophthalmicus
 Involvement of first Division (Ophthalmic)
of Trigeminal nerve

16. Symptoms
 Prodromal (fever ,fatigue ,malaise, headache)
 Burning pain (forehead ,eyelid ,nose)
 Vesicles
 Red Eye
 Watering/Discharge
 Photophobia
 Decreased vision

17. Signs (Ex.Ocular)
 Hutchinson’s Sign
( vesicles on forehead, upper eyelid, side &
tip of nose)

18. Hutchinson's sign

19. Signs (ocular)
 Conjunctivitis
(Hyperemia, discharge)

20. Signs (ocular)
 Keratitis
 Dendritic corneal ulcer ( Fine branching pattern)

21. Dendritic ulcer

22. Signs (ocular)
 Staining
Fluorescein
Rose Bengal

23. Signs (ocular)
 Corneal epithelial defects and ulcers

24. Signs (ocular)
 Anterior Uveitis (affects a third of patients)
 Red eye
 Cells, flare
 Posterior synachiae
 Keratic precipetates (KPs)
Posterior Synachiae

25. Anterior Uveitis
KPs

26. Signs (ocular)
 Episcleritis
 Scleritis
 Stromal keratitis
 Disciform keratitis

27. Complications
 Post herpetic neuralgia : pain that remains for more than
1 month after rash has healed
75% cases (esp. over 70yrs)
aggravated by minor stimuli (touch ,heat)
 Cranial nerve palsies
Third (most common)
Fourth & sixth
 Optic neuritis
 Encephlitis Rare
 Cranial arteritis
 Guillain-Barre syndrome

28. Ocular complications
 Eyelid scarring
 Raised IOP (steroid induced)
 Neurotrophic keratitis
 Chronic scleritis
 Lipid degeneration (cornea)

29. Treatment
Systemic :
Within 72hrs
Acyclovir 800mg 5 times daily
Famciclovir 500mg TID

30. Treatment
Local:
 Acyclovir skin ointment (rash)
 Topical Acyclovir
 Topical antibiotics (Chloramphenicol)
 Topical steroids (uveitis)

31. Treatment of Complications
Post herpetic neuralgia
 Cold compress
 Local CAPSAICIN oint (QID) /
LIDOCAINE oint
 Pain killers
 Oral Tricyclic antidepressants
No Post herpetic neuralgia

32. Message
 A common and treatable viral infection.
 Patient education/Counseling.
 Post herpetic neuralgia is extremely
painful condition.
 Can transmit chicken pox.