Foresee Your Next Patient
SHABNAM ZARGAR, MD, and PISEPONG PATAMASUCON, MD
University of Nevada
A 14-year-old boy presented to the emergency department with a 3-day history of progressive swelling of the right eye, vesicular lesions on the right upper eyelid, and watery to green-yellow right eye discharge. There was no history of right eye pain, fever, trauma, or similar lesions elsewhere on the boy’s body or in close contacts. The patient was pretreated with oral valacyclovir and tobramycin eye drops.
Physical examination showed vesicles just inferior to the eyebrow and superior middle eyelid, with crusted lesions on the lower medial eyelid and an erythematous, swollen right upper eyelid. A rapid herpes simplex virus (HSV) test was positive for HSV type 1. The patient was diagnosed with HSV preseptal cellulitis.
HSV blepharitis usually presents in one of 2 forms. Classically, it involves vesicles or pustules along the lid margin or periocularly over an erythematous and edematous base.3 These vesicles may ulcerate or form crusts within the first week of infection.3 The second form is an erosive-ulcerative type characterized by lid erosions or ulcers along the lid margin along with generalized swelling and erythema.3
Ocular HSV infection typically is unilateral and may occur in the absence of cutaneous and corneal lesions, or it may be associated with vesicles on the upper and lower eyelids.1 Eyelid vesicles typically are seen in primary ocular HSV, whereas corneal involvement is typical of recurrent ocular HSV.2 HSV blepharitis is more common in children. Presenting symptoms include pain, tenderness to palpation, increased lacrimation, and bulbar injection.3
Diagnosis may be clinical based on presentation of a unilateral vesicular rash in the distribution of the trigeminal nerve, Tzanck smear, biopsy, or culture.1 Differential diagnoses include herpes zoster, which usually is differentiated from HSV by culture testing.1 Herpes zoster usually affects people who are elderly or immunocompromised.3
HSV blepharitis has a risk of recurrence, with corneal involvement being common during recurrent episodes.2 Oral acyclovir can reduce the recurrence rate.2 Treatment usually is supportive in patients who are immunocompetent, with self-resolution occurring in approximately 2 weeks.1 In patients with extensive cutaneous involvement, systemic antivirals may be used along with a topical antibiotic ointment to prevent secondary bacterial infection.1,3 Neither topical nor oral antivirals have been proven to enhance the recovery of patients with HSV blepharitis.2,3 Ophthalmology referral might be necessary, especially when possible corneal involvement is a concern.2
1. Pierre P, Dahiya M, Starr J. Bilateral periorbital eruption in an immunocompromised host. Arch
2. Tsao CH, Chen CY, Yeh KW, Huang JL. Monthly recurrent herpes simplex virus blepharitis in a
boy for more than 10 years. Infection. 2003;31(4):257-259.
3. Sowka JW, Gurwood AS, Kabat AG. Herpes simplex blepharitis. Rev Optom. April 15, 2011;(suppl):7A-8A.