A 55 yo Hispanic male presented reporting pain along the left side of his head for one day, and an early rash. The skin rash was red, with a few vesicles and no lid edema. Vision was 20/20. Fields were full to confrontations, versions were full with no restrictions and pupils were normally reactive without an APD. Slit lamp exam found no chemosis, corneal involvement, or anterior chamber reaction. Vesicles were present on the upper lid. IOP was 19mmHg OD, 19mmHg. Dilated fundus exam found healthy optic nerves, maculae, vessels and intact periphery. The patient was prescribed valacyclovir 1 gm TID PO x 14 days with a Medrol dose pack.

The patient called the next day reporting the eye was swollen shut and the face covered by a rash. The patient was instructed to return to our office to see me as soon as they could get there. On day two, the lids were edematous and nearly shut. The rash covered the top of the head to below the left cheek, and lesions were found inside the mouth on the left side. The patient reported that he has started the valcyclovir but not the Medrol dose pak. Vision was slightly reduced to 20/25. Slit lamp exam found a healthy right eye but severe lid hyperemia and edema, and conjunctival chemosis OS. Cornea and anterior chamber were clear. IOP was 19mmHg OD, 18mmHg. 

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Tracy Swartz
Consultative Optometrist Laser Eye Center in Huntsville & Decatur, AL specializing in anterior segment. President, Optometric Corneal, Cataract, and Refractive Society (OCCRS)


  1. Excellent read; thanks for sharing, esp this most important paragraph:

    A meta-analysis of five placebo-controlled trials evaluating treatment using acyclovir alone compared to acyclovir plus steroids did not demonstrate a benefit of combination therapy on the patient’s quality of life or the incidence of post-herpetic neuralgia. (update) Steroids also increase the risk of secondary bacterial skin infection.

    In treating herpetic disease, systemic steroids carry a risk that often outweighs any potential benefit.

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