Ophthalmic zoster sine herpete manifesting as conjunctivitis, eyelid ulcer, and lymphadenopathy: a case report

Abstract

A 64-year-old man with a history of herpes zoster on his upper back presented with a small ulcer on the right lower eyelid and two lumps on the right upper neck as well as a 1-week history of redness and mild swelling of the right eye. Examination revealed follicular conjunctivitis with clear watery discharge, a 1.5 mm clear-based ulcer at the eyelid margin, and ipsilateral submandibular lymphadenopathy. There was no dermatomal vesicular skin rash, keratitis, uveitis, elevation in intraocular pressure, or posterior involvement. A conjunctival swab was positive for varicella-zoster virus, confirming the diagnosis of ophthalmic zoster sine herpete. The patient was treated with valacyclovir 1 g three times a day for 1 week. The conjunctival injection resolved on day 3, and the ulcer healed after 2 weeks. At the 6-month follow-up, the patient remained free from recurrence or long-term sequelae. Ophthalmic zoster sine herpete is an unusual form of herpes zoster ophthalmicus. Without the clues of cutaneous eruptions, diagnosis could be delayed, resulting in long-term ocular complications. Timely diagnosis and antiviral therapy are crucial for rapid resolution and preventing long-term sequelae.