The Clinical Picture

Painful eye with a facial rash

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A 75-year-old man presents 4 days after painful cutaneous lesions appeared on the left side of his face, associated with severe ocular pain. Two days before the eruption, he had had an intense headache, which was diagnosed as a tension headache and was treated with oral acetaminophen (Tylenol), but with no improvement.

Figure 1. Typical vesicular rash affects the first trigeminal branch dermatome without trespassing the midline.

He has a history of hypertension and hyperuricemia. No recent changes have been made in his medications. Physical examination shows grouped herpetiform vesicles on an erythematous base confined to the cutaneous surface and innervated by the left first trigeminal branch (Figure 1). Palpation detects regional preauricular and submaxillary lymphadenopathies.

Figure 2. Typical corneal fluorescein stain of dendritic keratitis under cobalt blue light.

Ophthalmologic examination with fluorescein stain shows moderate perilimbal injection and dendritic keratitis (Figure 2).

The remainder of his physical examination is normal. Laboratory tests, including red and white blood cell counts, hemoglobin, and basic metabolic and coagulation tests reveal no abnormalities.

Q: What is your diagnosis?

  • Allergic contact dermatitis
  • Herpes simplex
  • Varicella
  • Ramsay-Hunt syndrome
  • Herpes zoster ophthalmicus and herpetic keratitis

A: Herpes zoster ophthalmicus is the correct diagnosis. It represents a reactivation of the varicella zoster virus.1

Varicella zoster virus, like others of the herpes family, has developed a complex control of virus-host interactions to ensure its survival in humans. It lies dormant in the sensory ganglia and, when reactivated, moves down the neurons and satellite cells along the sensory axons to the skin.1 The reactivation is related to diminished cell-mediated immunity, which occurs as a physiologic part of aging, which is why the elderly tend to be the most often affected. 2 The incidence of herpes zoster varies from 2.2 to 3.4 per 1,000 people per year.3 Its incidence in people over age 80 is about 10 per 1,000 people per year.3


Herpes zoster typically presents as a dermatome-grouped vesicular eruption over an erythematous base, accompanied or preceded by local pain. It has two main complications, postherpetic neuralgia and ocular involvement. Postherpetic neuralgia is neuropathic pain that persists or develops after the dermatomal rash has healed.4 Independent predictors of postherpetic neuralgia are older age, severe acute pain, severe rash, a shorter duration of rash before consultation, and ocular involvement.5 It occurs in 36.6% of patients over age 60, and in 47.5% over 70.6 Persistent postherpetic neuralgia has been linked to suicide in patients over 70.7

Ocular infection occurs with involvement of the ophthalmic division of the fifth cranial nerve. Before the antiviral era, it was seen in as many as 50% of patients.8 Hutchinson’s sign is skin lesions on the tip, side, or root of the nose and is an important predictor of ocular involvement.1 Lesions may include folliculopapillar conjunctivitis, episcleritis, scleritis, keratitis (dendritic, pseudodendritic, and interstitial), uveitis, and necrotizing retinitis.

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