Herpes zoster sine herpete presenting with hyphema

Area of Science:

• Ophthalmology
• Infectious Diseases

Background:

• Herpes zoster sine herpete (HZSH) is a rare presentation of herpes zoster virus infection characterized by neurological symptoms without a cutaneous rash.
• Hyphema, or bleeding into the anterior chamber of the eye, can result from various causes, including ocular inflammation.

Observation:

• A 69-year-old man presented with hyphema and corneal edema following sandblast exposure, initially presumed to be traumatic.
• Ocular examination revealed anterior chamber inflammation, impaired corneal sensation, and elevated intraocular pressure, but no facial rash.
• Iris fluorescein angiography showed significant iris vessel abnormalities, suggesting an inflammatory or infectious etiology.

Findings:

• The patient's clinical presentation dramatically improved with oral acyclovir and topical steroids, consistent with herpes zoster uveitis.
• Despite initial improvement, the patient developed characteristic findings of herpes zoster ophthalmicus, including sectorial iris atrophy and persistent corneal anesthesia.

Implications:

• This case underscores the necessity of considering HZSH in the differential diagnosis of unexplained uveitis and hyphema, even in the absence of a typical dermatological presentation.
• Early recognition and treatment of HZSH are crucial to prevent potentially severe ocular complications and vision loss.
• Ophthalmologists should maintain a high index of suspicion for viral etiologies in patients presenting with acute anterior uveitis and hyphema.