Bilateral herpes zoster ophthalmicus in an immunocompetent patient

Bilateral herpes zoster ophthalmicus (HZO) is rare. We report a case of an immunocompetent patient with nonsimultaneous attacks of HZO in both eyes.

A 71-year-old female patient complained of blurred vision in the left eye for 1 week, which was treated with topical antiglaucomatous drugs due to elevated intraocular pressure. She denied any systemic diseases, but HZO had manifested as a rash with a crust over the right forehead skin 3 months earlier. Slit-lamp examination revealed localized corneal edema with keratin precipitates and mild anterior chamber reaction. Suspecting corneal endotheliitis, we performed aqueous tapping for detecting viral DNA, including cytomegalovirus, herpes simplex virus, and varicella zoster virus (VZV) DNA, through polymerase chain reaction (PCR) testing, but the PCR results were negative for all viruses. The endotheliitis resolved well after treatment with topical prednisolone acetate. However, the patient's blurred vision recurred in the left eye 2 months later. A dendritiform lesion on the left cornea was detected, and corneal scraping for PCR testing revealed VZV DNA. The lesion disappeared with antiviral treatment.

Bilateral HZO is uncommon, particularly in immunocompetent patients. When in doubt, physicians should perform tests such as PCR testing to help establish a definite diagnosis.