Varicella-Zoster Virus of the Eyelid
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A 66-year-old healthy man presented with a 9-day history of a progressively enlarging right lower eyelid lesion. He was seen by an outside ophthalmologist and prescribed oral amoxicillin/clavulanic acid (675 mg/125 mg) and ophthalmic tobramycin for presumed bacterial infection without improvement. The lesion was associated with ipsilateral facial numbness. On examination, he manifested a 9 × 6-mm ulcerated marginal lesion of the central right lower eyelid with surrounding edema and erythema. There was no associated lash loss and the region was nontender to palpation. There was notable hypoesthesia in the distribution of the trigeminalmaxillary branch.On examination, his best corrected visual acuity was 20/20 OU. The pupils were round and brisk without an afferent pupillary defect.

However,varicella-zostervirus (VZV) immunohistochemistry results were positive (Figure 2). The patient was treated with a 10-day course of treatment-dose acyclovir. Excellent healing was noted 1 month postoperatively. The maxillary branch hypoesthesia gradually resolved. Unlike the typical painful, vesicular lesions of VZV, the patient manifested a necrotic-appearing, nonpainful focal lesion. This case further emphasizes the illusive nature of herpes zoster, encouraging the physician to maintain a high clinical suspicion for this disease.

Source: https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2766088
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