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   Table of Contents      
Year : 1975  |  Volume : 23  |  Issue : 1  |  Page : 39-41

Herpes simplex uveitis in zoster ophthalmicus

1 Department of Ophthalmology, Institute of Medical Education and Research, Chandigarh, India
2 Department of Microbiology, Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
S P Dhir
Department of Ophthalmology, Institute of Medical Education and Research, Chandigarh
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Source of Support: None, Conflict of Interest: None

PMID: 169199

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How to cite this article:
Dhir S P, Jain I S, Sehghal S. Herpes simplex uveitis in zoster ophthalmicus. Indian J Ophthalmol 1975;23:39-41

How to cite this URL:
Dhir S P, Jain I S, Sehghal S. Herpes simplex uveitis in zoster ophthalmicus. Indian J Ophthalmol [serial online] 1975 [cited 2020 Aug 4];23:39-41. Available from: http://www.ijo.in/text.asp?1975/23/1/39/31341

Herpes simplex and herpes zoster have been proven antigenically and clinically to be diffe­rent viruses. The term "herpes" used by itself usually refers to herpes simplex. Zoster is a preferable term for herpes zoster or "shingles" to avoid confusion between the two.

The diagnosis of zoster lesion is often made clinically when the skin eruptions are charac­teristically distributed in the division of a nerve. Some times herpes simplex virus has been isolated from zoster like lesion with a dermato-neural distribution. The role played by herpes simplex virus in zoster lesions parti­cularly zoster ophthalmicus is controversial. In a recent publication Pavan-Langston and Mc Cully [4] have seriously questioned the role played by herpes simplex virus in zoster ophthalmicus infection.. They have failed to isolate herpes simplex virus from zoster ophthalmicus cases. We report two cases of zoster ophthalmicus (clinically typical) from whom herpes simplex virus was isolated and cultured from the skin and the aqueous humour.

  Case Reports Top

Case No. I:

K.C. 50 years old male come in with the com­plaint of redness, pain and diminution of vision in right eye for last forty five days. Patient started with pain followed by redness and watering, dimi­nution of vision from the right eye. After two days lie developed vesicles over the right half of fore­head and right side of the nose. In 20-25 days time the vesicles disappeared but the redness of the eye and defective vision persisted. He used local antibiotic ointment, drops and mydriatic drops with little impro­vement of the eye condition.

On examination, vision in right eye was reduced to hand movements. Palpebral aperture was narrow with lid oedema. There was marked circum-corneal congestion with corneal haze and epithelial oedema. There were folds in the Descemet's membrane and pigmented keratic precipitates were seen on the back of the cornea. Anterior chamber was deep with one third full with blood. The hyphaema was well settled. Iris pattern was blurred. Pupil was irregular. Corneal sensation was markedly diminished on the affected side. Intraocular pressure digitally appeared normal. Left eye was normal. There were scabs and drying up of vesicles on the right half of forehead and anaesthesia over the right half of forehead and tip of the nose.

Aqueous puncture was performed and aqueous mixed with blood was used for viral culture. Hyphaema was evacuated. A blood sample was drawn for serum antibodies. Patient was put on local atropine drops and Terramycin ointment three times a day. He was given prednisolone 15 mg. daily, tablet Tanderil thrice daily as well as vitamin C 500 mg. daily for a period of five days. Patient was given subconjunctival hydro­cortisone on the third day after admission. By fifth day eye condition was considerably better. Hyphaema cleared, corneal haze decreased. Cortisone was gradually tapered off and patient was discharged on 11 th day after admission in a satisfactory condition. In 30 days time eye was white and quiet. Pigment was seen on the back of cornea. Iris showed atrophic patches and pupil was irregular due to posterior synechiae. The visual acuity improved to 6/18. The other eye remained normal through out this period. There were pitted scars on the site of skin vesicles.

Aqueous humour for viral culture was mixed with equal amount of Hank's balanced salt solution and inoculated into chorio-allantoic of chick embryo. Herpes simplex virus was isolated and cultured from the chorio-allantoic membrane. The serum showed an antibody titre of 1:64 by neutralization test against herpes simplex virus type I.

Case No. 2:

R.N. 45 years old male patient presented with the complaints of swelling of the left upper lid. He had fever one day ago. On examination, patient had vesicular lesions on the nose and nasal side of the eye lids on the left side. There was oedema of the left upper lid. Cornea was clear and pupil was normally reacting. A smear and swab from the vesicles was sent for examination for viral aetiology. Giemsa stained smear showed giant cells with infra-nuclear inclusions. Culture showed growth of herpes simplex virus on chorio-allantoic membrane of developing chick embryo. He was advised to use crystamycin eye drops and Chloromycetin applicaps three times a day. He was referred to skin department and a diagnosis of herpes zoster ophthalmicus''(ophthalmic division of the trigeminal nerve). Left side was made. Patient was given analgesics, antibiotic drops and ointments locally on the skin and in the eye. Patient was again seen after 10 days with the complaints of redness and water­ing from the left eye for the last 8 days.

On examination, the visual acuity in left eye was reduced to 6/24. Palpebral fissure was narrow. There was marked conjunctival congestion and cornea was slightly hazy. Anterior chamber was slightly turbid. There was flare and keratic precipitates along with dispersal of pigment on the back of the cornea. Lens was clear and fundus glow could be seen. Tension was digitally full. Aqueous puncture was performed under local anaesthesia and sent for viral culture and a blood sample was drawn for antibodies. Patient was given local atropine eye drops and Chloromycetin eye oint­ment. He recovered over a period of one week. The visual acuity improved to 6/9 unaided. Pitted scars were present on the site of skin vesicles. The pupil on the affected side remained mid dilated. The aqueous cultured on chorio-allantoic membrane yielded herpes simplex virus. The serum had an antibody titre of 1:256 by neutralization test against herpes simplex virus type I.

  Discussion Top

The two cases reported had typical distribu­tion of skin vesicles on the half of forehead and tip of the nose. The clinical diagnosis of zoster infection of the trigeminal nerve with involvement of the ophthalmic division could be made with confidence. The diagnosis was further substantiated by the presence of vesicles and anaesthesia on the tip of the nose (involvement of nasociliary branch) and subsequent healing with pitted scars. However the diagnosis could not be confirmed by laboratory means due to paucity of facilities for the culture of zoster virus.

The isolation of herpes simplex virus from the skin vesicles in one patient raises the possibility of the disease being a simplex infec­tion However it does not preclude the diagnosis of zoster infection. The isolation of herpes simplex virus from the aqueous humour and a high antibody titers in the serum strongly support the coexistence of simplex infection as well in these cases. It is true that not all cases or majority of cases of zoster ophthalmicus have concurrent herpes simplex infection. The situation is more akin to herpes labialis after influenza, typhoid fever or malarial fever etc. Not all cases after an attack of influenza develop herpes labialis. In some of the patients having latent herpes simplex infection, the herpes virus is activated after an attack of influenza. Similarly, in some of the patients hav­ing latent herpes simplex infection in the eye the simplex virus is activated by zoster infection. Several workers have noted development of dendritic keratitis in zoster ophthalmicus, [2],[3],[4],[5]. Majority of them believe that the dendritic keratitis in zoster ophthalmicus is due to coexistence of herpes simplex infection. Kaufman et al [3] reported favourable response of dendritic keratitis in zoster ophthalmicus to iodoxyuri­dine and corticosteroids. Similarly Giles [2] reported two cases responding well to iodox­yuridine therapy. On the contrary as Pavan ­Langston and Me Cully [4] reported the cases of zoster ophthalmicus with dendritic keratitis, where they have demonstrated herpes zoster virus in the corneal lesions and not herpes simplex. They discount the presence of combined infection in ocular lesions.

The controversy has been so far limited to the corneal lesion and no literature is available on the uveitis occurring in zoster ophthalmicus. We believe that these two cases presented above had latent herpes simplex infection. The occurrence of zoster episode has reactivated the simplex virus. This will also explain the lag period observed between the onset of skin vesicles and uveitis. Herpes labialis is often seen after the peak of influenza or malaria is over.

Such a hypothesis of presence of latent herpes simplex virus in the eye is in very much accord with our previously reported Dhir et al, [1] observations on herpetic uveitis.

  Summary Top

Two cases of herpes zoster ophthalmicus are presented. During the course of the disease they developed severe iridocyclitis. Culture of the aqueous humour from these patients on chorio-allantoic membrane of developing chicken embryo yielded herpes sim­plex virus. In addition, examination of serum antibodies also revealed high antibody titers against herpes simplex. It is suggested that these two patients had latent herpes simplex infection and the zoster episode has activated the simplex uveitis.

  References Top

Dhir, S.P., Jain, I.S., Sehghal S. and Paul, R.S. 1973, Bulletin, PGI, s, 138.  Back to cited text no. 1
Giles, C., 1961, Eye Ear Nose Throat Mac, 48, 216.  Back to cited text no. 2
Kaufman, H., Dohlman C.H. and Martola E.L. 1963, Arch. Ophthal. 69, 468.  Back to cited text no. 3
Pavan-Langston, Deborah and James P. Mc Cully, 1973, Arch. Ophthal. 89, 25.  Back to cited text no. 4
Vaile, Acre, T., 1967, Amer. J. Ophthal, 63, 992.  Back to cited text no. 5


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