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Show Journal of Neuro- Ophthalmology 14( 1): 12- 14, 1994. © 1994 Raven Press, Ltd., New York Multifocal Choroidal Lesions A Rare Complication of Herpes Zoster Ophthalmicus A. M. McElvanney, F. R. c. s.( Ed.), F. R. c. ophth., and P. I. Murray, Ph. D., F. R. C. S., F. R. c. ophth. We document the case of a 76- year- old woman who developed multifocal choroidal lesions as an unusual complication of herpes zoster ophthalmicus. Key Words: Herpes zoster ophthalmicus- Corneal anesthesia- Uveitis- Iris atrophy- Choroidal lesions. Herpes zoster infection involves the ophthalmic branch of the trigeminal nerve in 8- 56% of cases, giving rise to a wide range of ocular complications ( 1). The anterior segment is predominantly affected, and dendritiform keratopathy, neurotrophic keratitis, uveitis, iris atrophy, and glaucoma may all occur. Fundal involvement is less common, but acute retinal necrosis ( 2), optic neuritis ( 1), multifocal choroiditis ( 3), and retinal detachment ( 4) have all been documented. We present a case of multifocal choroidal lesions occurring in a patient with herpes zoster ophthalmicus. From the Birmingham and Midland Eye Hospital, Birmingham, United Kingdom. Address correspondence and reprint requests to Mr. P. I. Murray, Academic Unit of Ophthalmology, Birmingham and Midland Eye Hospital, Church Street, Birmingham B3 2NS, U. K. CASE REPORT A 76- year- old woman presented to the Accident and Emergency Department, Birmingham and Midland Eye Hospital, with photophobia and blurred vision in her left eye. Left herpes zoster ophthalmicus had been diagnosed by her general practitioner 3 weeks earlier, and she had been treated with a week's course of oral Zovirax 800 mg five times a day. Past medical history was unremarkable and she was on a daily dose of prothia-den 75 mg for depression. On examination, her corrected visual acuities were 20/ 30 right and 20/ 60 left. There was a crusted, vesicular rash affecting the dermatome supplied by ophthalmic division of the left trigeminal nerve. Examination of the left eye revealed corneal anesthesia, a dilated pupil as a result of iris stromal atrophy, a moderate panuveitis, an intraocular pressure of 13 mmHg, and a normal fundus. Her right eye was healthy. She was treated with 2- hourly topical steroid with an improvement in inflammatory activity, but 4 months later cells persisted in the anterior chamber. On review 7 months after initial eye presenta- 12 FIG. 1. Fundus photograph of left eye showing well- demarcated multifocal choroidal lesions. FIG. 2. Early phase of a fundus fluorescein angiogram of the left eye showing cystoid macular edema and a partly infiltrative and atrophic appearance to the choroidal lesions. FIG. 3. Late phase of Fig. 2 with lighting up of the choroidal lesions consistent with some infiltrative response being present. 14 A. M. MCELVANNEY AND P. L MURRAY tion, her vision was unchanged. Erythema was present over the left side of the forehead, and her anterior segment signs remained the same. Fundal examination revealed scattered punched- out pale areas at the posterior pole and midperiphery ( Fig. 1) and cystoid macular edema. A differential diagnosis of multifocal choroidal atrophy or infiltration was made. Fundus fluorescein angiography was performed, which showed cystoid macular edema and a combination of infiltrative and atrophic change in the early phase of the angiogram ( Fig. 2). The later phase showed lighting up of the choroidal lesions consistent with some infiltrative response still being present ( Fig. 3). DISCUSSION Similar fundal signs in association with herpes zoster infection have been documented previously on only one occasion by Amano and colleagues ( 5). They described three male patients aged between 68 and 78, all of whom had numerous oval, punched- out areas of choroidal atrophy, predominantly affecting the midperiphery, and a recent history of herpes zoster ophthalmicus. In our patient, the clinical and fluorescein angiographic findings highlighted the difficulty in differentiating whether the choroidal lesions were due to atrophy, infiltration, or a combination of each. Ischemia is thought to be a significant mechanism of tissue damage in herpes zoster ophthalmicus ( 1). Amano and colleagues ( 5) noted that the distribution of atrophic choroidal areas corresponded to the innervation of the short ciliary nerves. They postulated that inflammation of the ciliary ganglion by the herpes zoster virus produced focal ischemia of the choroid resulting in atrophy. Similarly, the iris was affected via the long ciliary nerves, also resulting in atrophic changes. This theory would be consistent with some of the ocular signs noted in our case. It appears that multifocal choroidal lesions are a significant, but as yet, poorly documented complication of herpes zoster ophthalmicus. REFERENCES 1. Karbassi M, Raizman MB, Schuman JS. Herpes zoster ophthalmicus. Surv Ophthalmol 1992; 36: 395- 410. 2. Culbertson WW, Blumenkranz MS, Pepose JS, Stewart JA, Curtin VT. Varicella zoster virus is a cause of the acute retinal necrosis syndrome. Ophthalmology 1986; 93: 559- 68. 3. Bloom SM, Snady- McCoy L. Multifocal choroiditis uveitis occurring after herpes zoster ophthalmicus. Am ] Ophthalmol 1989; 108: 733- 5. 4. Lincoff HA, Wise GN, Romaine HH. Total detachment and reattachment of the retina in herpes zoster ophthalmicus. Am } Ophthalmol 1956; 41: 253- 6. 5. Amano Y, Ohashi Y, Haruta Y, Kinoshita S, Tano Y, Man-abe R. A new fundus finding in patients with zoster ophthalmicus. Am J Ophthalmol 1986; 102: 532- 3. / Neuro- Ophthalmol, Vol. 14, No. 1, 1994 |
