|Year : 2004 | Volume
| Issue : 4 | Page : 323-4
Maxillary zoster with corneal involvement.
S Jain, Mahesh K Rathore
Department of Ophthalmology, S S Medical College, Rewa, India
|Date of Submission||17-Mar-2003|
|Date of Acceptance||28-Sep-2003|
Department of Ophthalmology, S S Medical College, Rewa
Source of Support: None, Conflict of Interest: None
A case, of maxillary zoster with corneal involvement in a young patient is described. Corneal involvement in maxillary zoster (Medline search) is rare.
Keywords: Herpes zoster, corneal involvement
|How to cite this article:|
Jain S, Rathore MK. Maxillary zoster with corneal involvement. Indian J Ophthalmol 2004;52:323
Human herpes viruses are an important source of ophthalmic morbidity worldwide. These viruses are Herpes simplex type 1 and 2, Varicella Zoster, Epstein-Barr and Cytomegalovirus. Amongst these, zoster is a DNA virus, which predominantly affects old people. In children it appears as a generalised vesicular rash (chicken pox) caused by inhaled virus particles. The virus may then reside dormant in sensory nerve ganglia for many years. A second peak in the distribution of the nerve occurs in the elderly, probably by its reactivation due to declining immunity. Involvement of the trigeminal nerve by the zoster virus is second in frequency after the thoracic region. In trigeminal zoster, the effect on the ophthalmic division is far more common (20 times) than the maxillary and mandibular. Corneal involvement with ophthalmic zoster occurs in two-thirds of cases and has not been reported with maxillary zoster.
| Case report|| |
A 28-year-old male presented to the Ophthalmic Department of our centre with complaints of decreased vision in the right eye for five days along with vesicular eruptions over the right cheek for 12 days. Eruptions were noted in successive crops over the right cheek, side of the nose, upper lip and temple. Eruptions were heralded by mild fever, malaise, and piercing pain over the right cheek for 2 days. The vesicles were followed by pain in the right upper teeth with difficulty in chewing.
There was no history of ocular trauma or inflammation. There was no positive history of chickenpox in childhood or any other systemic illness later.
Visual acuity in the right eye was 5/60 improving to 6/24 with pinhole. There was mild lower lid oedema and ciliary congestion, a limbal phlyctenular lesion associated with conjunctival congestion at 9 o'clock position [Figure - 1], bottom), a diffuse patch of anterior stromal infiltration in the lower two/third of the cornea without epithelial involvement [Figure - 1] top). Corneal sensations were diminished, fluorescein staining was negative. On slitlamp examination there was no evidence of uveitis. Intraocular pressure was 14.6 mm of Hg. Ocular movements were normal. Apart from this, the patient had multiple vesicular eruptions in various stages over the malar prominence of right cheek, side of nose, temple, upper lip, and an isolated vesicle below the right angle of the mouth [Figure - 2].
There was ulceration on the right side of the mucous membrane of upper lip and cheek The left eye was normal with 6/6 vision. E.N.T. and dental examination supported the diagnosis of maxillary zoster. No other illness was found on medical examination. Serological tests for HIV and syphilis were negative. Blood sugar was normal. Complete blood picture showed no significant changes. A clinical diagnosis of maxillary zoster was made based on the typical sharp limitation of disseminated vesicular eruptions with a specific area of neural distribution.
The patient was treated with oral acyclovir 800 mg. five times a day for seven days, supplemented by injection B1-B6-B12, non-steroidal anti-inflammatory analgesics along with local application of ciprofloxacin ointment 0.3% over the vesicles. A combination of tobramycin 0.3% and dexamethasone sodium phosphate 0.1% drops in a tapering dose was given for three weeks. Response to treatment was encouraging. After six weeks of follow-up the rashes disappeared [Figure - 3] and the cornea was clear with visual acuity 6/6. Corneal sensation was diminished and the patient had mild toothache when chewing on the right side.
| Discussion|| |
The virus resides in its ganglia in trigeminal herpes and when reactivated spreads from the ganglia along the sensory nerve to the specific area of distribution of its three branches. In zoster ophthalmicus vesicles usually involve the eye, its adnexae and the skin of the forehead. Maxillary and mandibular nerve involvement occurs rarely and may cause vesicles over the face. Corneal involvement with zoster ophthalmicus is common and it occurs due to affection of the nasociliary, a branch of the ophthalmic nerve but its involvement in maxillary zoster is uncommon. Protean manifestations of zoster ophthalmicus keratitis include, in decreasing order of frequency, punctate keratopathy, pseudodendritis, anterior stromal infiltrate, keratouveitis, neurotrophic keratitis, exposure keratitis, disciform keratitis, peripheral ulcerative keratitis and sclero keratitis. These lesions might be infectious, immune response to soluble viral antigen or both. In our patient the rashes appeared only in the area of maxillary nerve distribution (sparing the ophthalmic nerve area) with anterior stromal infiltration of cornea which led to the clinical diagnosis of maxillary zoster with corneal involvement.
It is very unusual for zoster to involve maxillary or mandibular without ophthalmic division but occasional reports have appeared describing zoster affecting these branches but sparing the ophthalmic division.
In the present case the corneal involvement can be attributed to the following factors.
Zoster virus traverses by direct neuronal connection and / or by direct spread through the tissue to other nerves, is able to cause a wide variety in severity of disease. There are established rami communications between nasal branches of maxillary with external nasal branches of the anterior ethmoidal nerve branch of nasociliary (ophthalmic nerve). These neuronal connections may explain the involvement of cornea with isolated maxillary zoster.
It is unusual for zoster to spare the ophthalmic division. The maxillary zoster may some times precede ophthalmic zoster, and zoster ophthalmicus may occur without skin rashes, involving only the cornea or iris (zoster sine herpete). In the present case the maxillary might have also preceded an ophthalmic zoster but in zoster sine herpete form.
Occasionally the lacrimal nerve is absent and is replaced by the zygomaticotemporal branch of maxillary nerve, sometimes conversely. In this case there could be a possibility of mal innervation of cornea with a branch of the maxillary nerve.
Varicella zoster and herpes zoster are two distinct clinical diseases caused by organisms which are identical, antigenically and on a molecular biologic level. In varicella infection direct corneal involvement is a rarity (viremia), but the limbal vesicle may indirectly implicate the cornea to manifest as marginal infiltration (which is also rare). Similarly in this case there may be the possibility of secondary corneal involvement from the limbal phylectenular lesion.
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[Figure - 1], [Figure - 2], [Figure - 3]