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Case #: 00-01 - Contributor: Ronald D. Plotnik, M.D.
Brief Hx: This 70 year-old man developed culture positive Herpes Zoster Ophthalmicus but presented tome with a 2 x 4" forehead ulcer, lid skin mostly gone, and practically no epithelium of the conjunctiva and none on the cornea. He healed his forehead blister with oral steroids but the eye has gotten worse, despite aggressive lubrication and some steroid. He was seen by the rheumatology department and they felt this was in the category of a Stevens-Johnson type reaction. At this point, there is conjunctivalization of the peripheral cornea, a deep gutter central to this, and a central island that appears keratinized except for what does stain with fluorescein inferiorly. Any advice would be extremely helpful. The patient is reluctant to have any tissue taken from the other eye (i.e., limbal autograft). Photos: Please click on a photo to see an large size photos.
Comments: 1. From James Chodosh, M.D. (james-chodosh@uokhsc.edu): Perhaps, chronic varicella infection of the ocular surface has been ruled out by skin biopsy and culture. If not, he should first have a ten to 14 day course of oral antiviral at the zoster dose (e.g. acyclovir 800 mg 5 X/day), because he may have persistent varicella virus replication in his ocular surface and skin epithelium. 2. From Charalamb Siganos, M.D., Ph.D. (csiganos@danae.med.uoc.gr) Quite an interesting and challenging case. It looks like there is definitely an immune inflammatory reaction (I would avoid using the term S-J like, since it excludes other autoimmune conditions). May be OU conjunctival biopsy for immunofluorescence should be done, and treatment with intense systemic steroids along with cover of systemic Acyclovir. Topically, since the patient is refusing LAU, punctal occlusion along with lubrication, antibiotic cover and may be tarsorrhaphy or amniotic membrane as a patch can prevent further deterioration. I agree with Dr. Chodosh on systemic acyclovir. But didn't the patient receive it for his skin blister? He got only systemic steroids for that? Looking forward to other opinions and Dr. Tseng's management for this case. 3. From Scheffer Tseng, M.D., Ph.D.: We have another similar case who was HIV positive and suffered from acute HZO involving the skin and the eye with peripheral corneal ulcer, keratouveitis, hypopyon, and corneal edema and inflamed surface (see photo). The culture was negative for any microbes and the inflammation and ulceration did not respond to oral Acyclovir and topical steroid and antibiotics. We applied AMT as a patch out of no choice and the surface was remarkably recovered in a short period of 8 days with total resolution of inflammation.
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