Herpes zoster ophthalmicus with dependent contralateral edema

A 72-year-old man with multiple myeloma presented with an acute, progressive, exquisitely painful vesicular rash on his left face (Figure 1). Intravenous acyclovir was started to treat herpes zoster ophthalmicus. The following day, new periorbital edema was noted around his right eye (Figure 2). No other vesicles or rash were observed to suggest disseminated herpes zoster. After serial ophthalmologic evaluations, the right-sided periorbital edema was determined to be dependent edema from the patient positioning himself exclusively on his right side due to the allodynia he felt on the left side of his face. The edema resolved spontaneously by changing sleeping position (Figure 3).

Herpes zoster ophthalmicus (HZO) results from reactivation of the varicella zoster virus in the ophthalmic (V1) branch of cranial nerve V. As cranial nerve V innervates the cornea, HZO can lead to sight-threatening keratitis, uveitis, or retinal necrosis. Vesicular lesions on the tip or side of the nose, known as “Hutchinson's sign,” indicate nasociliary branch involvement and predict a higher risk of ocular complications.¹ HZO constitutes an ophthalmologic emergency that requires close evaluation by ophthalmology. Although the vesicular lesions of herpes zoster remain confined to a dermatomal distribution, the inflammation-associated edema can freely cross fascial planes. Acute periorbital edema in the contralateral eye should raise concern for disseminated disease, preseptal cellulitis due to bacterial superinfection, or acute angioedema. These diagnoses were considered however the clinical picture combined with the rapid onset and resolution in this case supported a benign, positional cause.

The author declares no conflicts of interest.

The images featured in this manuscript were obtained and published with written informed consent of the patient.