WILLIAM TOWNSEND, OD
Ophthalmicus, Part 1
and blurring as well. Her physician diagnosed herpes zoster and prescribed Valtrex
q8h and Darvocet-N q6h. Christi complained of nausea and vomiting that began shortly
after her initial dose of narcotic analgesic.
Signs and Symptoms
Her presenting visual acuities were 20/25 OU. Gross external examination
revealed a diffuse maculopapular rash on the left side of her face and grade 3+
swelling of the upper lid and periorbital skin (Figure 1). The left conjunctiva
showed grade 3+ injection in all quadrants, and follicles were apparent on the tarsal
Examination of the cornea revealed multiple, slightly elevated,
dendrite-shaped lesions that stained both with fluorescein and lissamine green.
The anterior chamber was free of flare or cells. We diagnosed varicella zoster (shingles)
and herpes zoster ophthalmicus (HZO). We prescribed topical Voltaren (Novartis Pharmaceuticals)
drops q4h, and Systane (Alcon) every hour.
The following day, Christi reported little improvement in her
symptoms. Slit lamp signs were unchanged except for reduced injection OS. Applanation
tensions were OD 13 mmHg OS 10 mmHg.
We instructed Christi to discontinue the Darvocet and begin ibuprofen
400mg q4h. We also added Pred Forte (Allergan) every
hour. The next day she reported better ocular comfort and no vomiting.
We gave her a tapering schedule for the steroid.
Four days later, Christi's skin lesions had begun to crust, and
there was remarkably less lid edema. The areas of dendritic corneal staining were
almost resolved, and no injection remain-ed. Tensions were unchanged.
Varicella zoster virus (VZV), a
member of the herpes virus family, is a highly contagious agent
that causes chicken pox in children and shingles in adults. Approximately 90 percent
of the general population is sero-positive for VZV. Shingles is 15 times
more common in individuals over 50 years old and in HIV patients.
It occurs most commonly in the spring. The virus may remain latent for decades,
but reactivates when a decrease in cell-mediated immunity occurs.
Varicella zoster is characterized by fever, malaise and a maculo-vesicular
rash. Patients fre-
quently report hyperesthesia, paresthesias and pruritus.
These lesions follow dermatomes and are invariably unilateral. The thoracic and
lumbar dermatomes prevail in incidence.
Ocular complications occur in approximately 50 percent of all
patients who have involvement of the trigeminal nerve. HZO is potentially the most
devastating of all manifestations of varicella zoster, ranging in severity from
an uncomplicated but uncomfortable conjunctivitis to sight-threatening uveitis,
glaucoma and disciform keratitis. CLS
LENS SPECTRUM/JULY 2006
is a 37-year-old female whose primary care provider referred her to our office.
Three days earlier, she developed unilateral facial pain and a rash above her left
eye. She noted ocular discomfort
1. Facial rash and ocular swelling from varicella zoster.
Dr. Townsend is in private
practice in Canyon, Texas, and is a consultant at the Amarillo VA Medical Center.
E-mail him at email@example.com.
Contact Lens Spectrum, Issue: July 2006