Abstract
Purpose
To report a case of a sterile iris abscess associated with herpes zoster ophthalmicus (HZO).
Observations
A 69-year-old African American female presented to SUNY Downstate Medical Center complaining of left-sided eye pain for two weeks. The patient had a best-corrected visual acuity of 20/30 OD and 20/200 OS. On external exam, vesicles were noted on the left upper lid and tip of the nose. Anterior segment exam was notable for decreased sensation without epithelial defects. The patient had 2+ stromal edema with 3+ cell and flare. The iris was flat with 1+ nuclear sclerosis OU. The intraocular pressure (IOP) was 14 mmHg OD and 40 mmHg OS. The patient was diagnosed with HZO with secondary uveitic glaucoma.
At ten weeks, anterior segment inflammation resolved and IOP stabilized. However, an iris nodule was noted superior nasal which continued to enlarge by 16 weeks follow up. Iris ultrasound revealed a 3 × 3 mm elevated lesion with internal homogeneity suggestive of an abscess.
At five months, a dense, mature cataract developed. The patient underwent cataract extraction with sector iridectomy. Gram staining and cultures were negative for organisms but positive for polymorphic neutrophils. Histopathology revealed fibrosis, surface necrosis, and stromal infiltration with chronic inflammatory cells consistent with chronic iritis and a sterile abscess secondary to HZO.
Conclusions and Importance
HZO is associated with a range of ocular sequelae with acquired iris nodule only mentioned once in the literature. As the second documented case, our findings will add to the general fund of knowledge regarding iris lesions and HZO.
1
Introduction
Varicella Zoster Virus (VZV), also known as shingles, is a common disease treated by healthcare practitioners. About 30% of individuals will develop shingles at least once in their lifetime, with a majority of individuals being 65 or older. It most often presents as a painful, vesicular rash which follows the dermatome.
When zoster involves the ophthalmic division of the fifth cranial nerve (V1) it is known as herpes zoster ophthalmicus (HZO). Ocular involvement occurs in about 10–20% of HZO cases, typically preceded by dermatomal vesicles which involve the tip or side of the nose, known as Hutchinson’s sign. Ocular findings most commonly include conjunctivitis with severe pain, episcleritis/scleritis, uveitis with increased intraocular pressure, keratitis, corneal scarring, ptosis, and less commonly retinal necrosis.
Another rare potential sequelae of HZO includes iris nodules which has only been previously documented once in the literature. Thus we present the second case of an iris nodules associated with HZO.
2
Case presentation
A 69-year-old African American female presented to SUNY Downstate medical center complaining of left-sided eye pain for two weeks duration. The patient had a best-corrected visual acuity (BCVA) of 20/30 OD and 20/200 OS. On external exam, vesicles were noted on the left eyebrow, left upper lid, and the tip of the nose. Anterior segment exam was notable for decreased sensation without epithelial defects or dendritic patterns. The patient had 2+ stromal edema with 3+ cell and flare. The iris was flat with 1+ nuclear sclerosis OU. The intraocular pressure (IOP) was 14 mmHg OD and 40 mmHg OS. Fundus exam was unremarkable for both eyes.
The patient was diagnosed with HZO with secondary uveitic glaucoma. She was started on IOP-lowering medication and anti-inflammatory agents including timolol BID, acetazolamide 500mg BID, prednisolone 1% Q2H, and atropine 1% BID. The patient was seen three days later. Anterior segment exam revealed nodular scleritis over the superior limbal area ( Fig. 1 ). Anterior segment inflammation and elevated IOP continued. Thus, previous treatment modalities were continued.
Five-week follow-up revealed growth of a limbal nodule at the 12 o’clock position. Aspiration of the limbal vesicle revealed purulent discharge. Gram staining and cultures were negative for organisms but positive for polymorphic neutrophils (PMNs).
At ten weeks, anterior segment inflammation resolved following a slow tapper of topical prednisolone along with stabilization of IOP. However, an iris nodule was noted superior nasal, which continued to enlarge by 16 weeks follow up. A workup for sarcoidosis and metastatic cancer was negative. A fast-growing iris melanoma versus an abscess was suspected. Iris ultrasound was performed, revealing a 3 × 3 mm elevated iris lesion within the anterior chamber. The lesion appeared solid with internal homogeneity suggestive of an abscess. The lesion did not extend to the ciliary body.
At five months, 360-degree posterior synechiae was noted with iris bombe. The iris mass partially regressed but a dense, mature cataract developed ( Fig. 2 ). The patient underwent cataract extraction with sector iridectomy at eight months from presentation. During iridectomy, a pocket of loculated, yellowish purulent fluid was observed. Gram staining and cultures were negative for organisms but positive for PMNs. Pathology of excised iris mass revealed perivascular collagenization, an area of surface necrosis with neutrophils, and stromal infiltration with chronic inflammatory cells, plasma cells, and lymphocytes ( Fig. 3 ). The pathology report was consistent with chronic iritis and a sterile iris abscess from a previous HZO infection. Follow up in the subsequent years documented no recurrence of iris nodules.
