Description

An 87-year-old immunocompetent man presented with left-sided herpes zoster ophthalmicus (HZO). His symptoms began with facial dysaesthesia, before erupting into a vesicular rash affecting the left forehead, periorbital skin and nose. The tip of the nose was not involved (figure 1). HZO occurs due to reactivation of latent varicella-zoster virus (VZV) in the trigeminal ganglion. The reactivated virus has a predilection for the ophthalmic division of the trigeminal nerve.1 Reactivation is more common in immunocompromised persons and in the elderly.2

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Figure 1

A vesicular rash affecting the left forehead, periorbital skin and nose but sparing the tip of the nose. This is known as negative Hutchinson's sign.

The ophthalmic division of the trigeminal nerve divides into three main branches: the frontal nerve, the lacrimal nerve and the nasociliary nerve. The nasociliary branch innervates the ciliary body, iris, cornea and conjunctiva. Its terminal branch is the anterior ethmoidal nerve, which innervates the sides of the tip of the nose (alae nasae) via the external nasal nerve.

Hutchinson3 observed that ocular involvement is more commonly seen if the HZO rash involves the alae nasae. Up to 85% of such cases may develop ocular involvement1; all such patients should have an urgent ophthalmic examination.4 If Hutchinson's sign is absent ocular involvement is less likely, however can still occur and is likely to be present if the patient reports reduced vision, eye pain or photophobia. Additionally, reduced corneal sensation is a useful sign of ocular involvement. If these features are present immediate referral to ophthalmology is needed.

In this case the alae nasae was spared, and the patient denied any eye pain or photophobia. A comprehensive eye examination revealed no evidence of anterior or posterior segment inflammation. The patient was managed with systemic acyclovir and prophylactic topical antibiotic ointment to protect the ocular surface.