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Varicella-Zoster Virus of the Eyelid

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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 not painful but 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 (Figure 1). There was no associated lash loss and the region was nontender to palpation. There was notable hypoesthesia in the distribution of the trigeminal maxillary branch. On examination, his best-corrected visual acuity was 20/20 OU. The pupils were round and brisk without an afferent pupillary defect. He manifested full extraocular movements. The anterior segment examination, applanation tonometry, and dilated fundus examination results were within normal limits.

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Varicella-zoster virus

C. Excisional biopsy

Excision of the lesion with biopsy was performed. Continued antibiotic therapy (choice A) was not chosen given previous treatment failure and wound debridement (choice B) without a biopsy would not establish a diagnosis. Lastly, there was no clinical evidence of associated orbital pathology to warrant a computed tomography scan of the orbits (choice D). Lesion removal was performed via wedge resection and primary closure. Hematoxylin-eosin staining demonstrated ulceration and necrosis (Figure 2) with no evidence of viral cytopathic effect or malignancy. However, varicella-zoster virus (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.

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Article Information

Corresponding Author: Marie B. Somogyi, MD, TOC Eye and Face, 3705 Medical Pkwy, Ste 120, Austin, TX 78705 (msomogyi@tocaustin.com).

Published Online: May 21, 2020. doi:10.1001/jamaophthalmol.2020.0575

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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Gershon  AA , Breuer  J , Cohen  JI ,  et al.  Varicella zoster virus infection.   Nat Rev Dis Primers. 2015;1:15016. doi:10.1038/nrdp.2015.16PubMedGoogle ScholarCrossref
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Liesegang  TJ .  Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity.   Ophthalmology. 2008;115(2)(suppl):S3-S12. doi:10.1016/j.ophtha.2007.10.009PubMedGoogle ScholarCrossref
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Jordan  DR , Mawn  L , Anderson  RL . Forehead, eyebrows, eyelids, and canthi. In: Jordan  DR , Mawn  L , Anderson  RL , eds.  Surgical Anatomy of the Ocular Adnexa: A Clinical Approach. 2nd ed. Oxford University Press; 2012:38-40.
4.
Paquin  R , Susin  LF , Welch  G , Barnes  JB , Stevens  MR , Tay  FR .  Herpes zoster involving the second division of the trigeminal nerve: case report and literature review.   J Endod. 2017;43(9):1569-1573. doi:10.1016/j.joen.2017.03.004PubMedGoogle ScholarCrossref
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Molina-Ruiz  AM , Santonja  C , Rütten  A , Cerroni  L , Kutzner  H , Requena  L .  Immunohistochemistry in the diagnosis of cutaneous viral infections—part I: cutaneous viral infections by herpesviruses and papillomaviruses.   Am J Dermatopathol. 2015;37(1):1-14. doi:10.1097/DAD.0000000000000203PubMedGoogle ScholarCrossref
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