A 65-year-old female without any significant past medical history presented to the emergency department with left eye pain and redness. She also reported a developing rash to left side of her face over the last 24 hours.
Fluorescein exam of the left eye
Skin: Vesicular rash over the medial aspect of left eyelid, nasal bridge, and tip of the nose.
Eyes: Pseudo-dendritic lesion of the left cornea under fluorescein stain, and mild conjunctival injection to left eye.
No labs obtained
It is a classic finding of herpes zoster ophthalmicus and presents as vesicles on the tip of the nose.
The nasocilliary branch of the trigemital nerve innervates the cornea, lateral dorsum, and the tip of the nose. In patients with this finding, ocular involvement of herpes zoster is much more likely.
In non-immunocompromised adults, Hutchinson’s sign has also been found to be a strong predictor of sight-threatening complications including ocular inflammation and corneal denervation in herpes zoster ophthalmicus. A high index of suspicion for emergency physicians is still required as the absence of Hutchinson’s sign does not exclude ocular disease involvement.
Take Home Points: Herpes zoster ophthalmicus
- This is serious ophthalmologic condition that can result in loss of vision, post-herpetic neuralgia, and stroke. Referral for specialist care can prevent or reduce the likelihood of complications.
- Classic symptoms: Headache and neuralgia along the distribution of the ophthalmic division of the trigeminal nerve; typically can be accompanied by eye redness, pain, photophobia, and changes in vision.
- Because of the high risk for vision loss, herpes zoster ophthalmicus must be treated urgently.
- Immunocompetent patient: Oral antiviral medication such as acyclovir or valacyclovir
- Immunocompromised patient: IV acyclovir and hospitalization is recommended. Neuroimaging is advised in patients with vision loss.