One in three people in the U.S. will experience herpes zoster (HZV), which is characterized by a painful, unilateral erythematous skin rash along a dermatome. In herpes zoster ophthalmicus (HZO), ocular involvement results from infection of the nasociliary branch of the V1 division of the trigeminal nerve which can cause pseudodendrities, immune stromal keratitis, or uveitis. Multi-dermatomal HZV infection has been reported in the literature typically in immunocompromised patients. We report a case of non-vesicular HZO presenting as immune mediated stromal keratitis subsequent to resolution of V2 HZV dermatitis. The term zoster sine herpete is used to describe the rare occurrence of zoster complications without development of skin vesicles in the affected dermatome.
An 82 y/o Hispanic male presented with a swollen, painful right lower eyelid & cheek area for 2 days duration. On examination, vesicles were observed following the V2 dermatome, encompassing the right lower eyelid without noted corneal involvement; the patient was given famciclovir 500mg tid for 7 days. Upon 1 month follow up the patient’s V2 vesicles significantly improved; however, there was newly noted moderate central anterior stromal corneal haze OD with the patient complaining of FBS, redness, & epiphora. The patient was diagnosed with non-vesicular HZO presenting as immune-mediated stromal keratitis & started on 1% prednisolone acetate tid & valacyclovir 500mg bid. Vision slowly improved from 20/40 to 20/25 after several months of treatment with mild stromal haze & endothelial pigmentation remaining.
Optometrists should be cognizant that HZV can sometimes affect multiple dermatomes & that HZO can present even in the absence of vesicles in the affected dermatome, termed zoster sine herpete. This case serves to highlight the importance of 1 month follow up after initial presentation of HZV in any dermatome to monitor for the late manifestation of immune mediated stromal keratitis.