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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 714-715

Herpes zoster masquerading viral endophthalmitis after ozurdex intravitreal implant


1 Retina and Cataract Services, Dhami Eye Care Hospital, Ludhiana, Punjab, India
2 Cornea, Cataract and Refractive Clinic, Dhami Eye Care Hospital, Ludhiana, Punjab, India
3 Cataract and Refractive Clinic, Dhami Eye Care Hospital, Ludhiana, Punjab, India

Date of Submission27-Dec-2021
Date of Acceptance24-Feb-2022
Date of Web Publication16-Jul-2022

Correspondence Address:
Dr. Abhinav Dhami
Dhami Eye Care Hospital, 82-b Kitchlu Nagar, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3163_21

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  Abstract 


A 64-year-old gentleman presented with decreased vision, raised intraocular pressure, and anterior chamber reaction of 1+ with grade 3 vitreous exudates on day 5 after intravitreal Ozurdex® implant. Microbiological culture showed no bacterial or fungal growth. On suspicion of viral endophthalmitis, the patient was started on topical prednisolone, moxifloxacin, atropine, dorzolamide, and timolol eye drops and oral valacyclovir 1 g twice a day for 10 days. On day 9, a vesicular eruption was noted on the left forehead, confirming the diagnosis of herpes zoster-related shingles infection. Complete resolution of inflammation was noted on day 30. This is the first case report highlighting the occurrence of ocular zoster infection after an intravitreal Ozurdex® implant.

Keywords: Endophthalmitis, Ozurdex® implant, viral uveitis


How to cite this article:
Dhami A, Dhami NB, Singh G. Herpes zoster masquerading viral endophthalmitis after ozurdex intravitreal implant. Indian J Ophthalmol Case Rep 2022;2:714-5

How to cite this URL:
Dhami A, Dhami NB, Singh G. Herpes zoster masquerading viral endophthalmitis after ozurdex intravitreal implant. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2022 Aug 14];2:714-5. Available from: https://www.ijoreports.in/text.asp?2022/2/3/714/351177



Viral anterior uveitis (VAU) is characterized by anterior uveitis (AU) with elevated intraocular pressure (IOP), diffuse stellate keratic precipitates (KPs), presence of pigmentation in active KPs, and iris atrophic changes. The most commonly implicated viruses are herpes simplex (HSV), varicella-zoster (VZV), cytomegalovirus (CMV), and rubella.[1] Herpes zoster ophthalmicus (HZO) presents with severe pain followed by a vesicular eruption in the dermatome of the ophthalmic division along the trigeminal nerve, and the involvement of the tip of the nose is a predictor for ocular inflammation. HZV-related AU occurs in 40%–60% of HZO in immune-competent patients.[2] Herein we present a case of HZV-related uveitis masquerading endophthalmitis post an intravitreal Ozurdex® (dexamethasone implant).


  Case Report Top


We report a case of a 64-year-old gentleman who underwent intravitreal Ozurdex® implant for branch retinal vein occlusion with macular edema (ME) in the left eye [Figure 1]a and [Figure 1]b. On postoperative day (POD) 5, the patient presented with a visual acuity of 2/60 on Snellen's chart with a raised IOP of 38 mm Hg, with KPs on the corneal endothelium [Figure 2]a with an anterior chamber (AC) reaction of +1. There was diffuse vitreous haze 3+[3] with obscuration of the optic disc [Figure 1]c and retinal details with localized exudates around the implant [Figure 1]d. An aqueous tap was taken for gram and KOH stain and microbiological culture, which showed no bacterial or fungal growth. On suspicion of viral uveitis, the patient was started on eyedrops prednisolone (1%), moxifloxacin (0.5%) 1 hourly, atropine eye drops (1%), and dorzolamide and timolol twice a day with oral valacylovir 1 g twice a day for 10 days. On POD 9, the patient's IOP was 18 mm Hg, and a vesicular eruption was noted on the left forehead with no associated dermatomal pain [Figure 3]a. A dermatologist consultation was taken and a diagnosis of herpes zoster (HZV) shingles reactivation was established. Additionally, the serology investigation of VZV-IgG came positive (3638 mIU/mL), and IgM was negative. On POD 12, the visual acuity improved to 6/60 in the left eye, with vitreous haze of 2+ [Figure 1]e, with minimal AC reaction [Figure 2]b. On POD 15, vitreous haze was 1+, with a decrease in the exudates around the Ozurdex® implant. There was complete resolution of the vesicles [Figure 3]b and vitreous haze with complete resolution of vitreous exudates [Figure 1]f and around the implant by POD 30 with a visual acuity of 6/12 on Snellen's chart with resolution of the ME in the left eye. The oral antiviral medication was continued 200 mg twice daily for 2 months as prophylaxis in view of sustained dexamethasone implant and for preventing recurrence. This case highlights a diagnostic dilemma of steroid implant-related activation of HZV uveitis and its management while keeping the implant in situ.
Figure 1: (a) Shows the fundus photo of the left eye with BRVO; (b) shows macular edema on the OCT; (c and d) show the diffuse vitreous haze with obscuration of retinal details on and the exudates around the implant (blue star) on POD 5; (e) shows the fundus image on POD 12 with resolving exudation after starting the oral antiviral therapy; (f) shows fundus image with complete resolution of the exudation and the resolving hemorrhages of the BRVO on POD 30

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Figure 2: (a) Shows the presence of diffuse pigments on the corneal endothelium on POD 5 (orange arrow); (b) shows the resolution of anterior chamber reaction with minimal KPs on endothelium on POD 30 (blue arrow)

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Figure 3: (a) Shows the vesicular eruption (blue circle) on POD 9 on the left forehead; (b) shows the resolved vesicles on POD 30

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  Discussion Top


Dexamethasone intravitreal implant (Ozurdex®) injections are effective in managing venous occlusion-related macular edema by reducing vascular permeability and inhibiting inflammatory mediators.[4] The associated complications mainly include increased intraocular pressure, cataract, endophthalmitis, and acute retinal necrosis.[4] The development of viral activation after the dexamethasone implant can be due to localized steroid-induced immunosuppression.[4]


  Conclusion Top


This is the first case report highlighting the combined occurrence of HZO with viral posterior uveitis after Ozurdex® implant. Early suspicion and initiation of oral antiviral therapy provide early resolution and better visual outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Babu K, Konana VK, Ganesh SK, Patnaik G, Chan NS, Chee SP, et al. Viral anterior uveitis. Indian J Ophthalmol 2020;68:1764-73.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Zaal MJ, Volker-Dieben HJ, D'Amaro J. Visual prognosis in immunocompetent patients with herpes zoster ophthalmicus Acta Ophthalmol Scand 2003;81:216-20.  Back to cited text no. 2
    
3.
Madow B, Kempen JH. Grades of Vitreous Clarity. The Uveitis Atlas 2020:45-50.  Back to cited text no. 3
    
4.
Zhang ZY, Liu XY, Jiang T. Acute retinal necrosis following dexamethasone intravitreal implant (Ozurdex®) administration in an immunocompetent adult with a history of HSV encephalitis: A case report. BMC ophthalmol 2020;20:1-7.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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