TNOA Journal of Ophthalmic Science and Research

: 2022  |  Volume : 60  |  Issue : 2  |  Page : 210--211

Herpes zoster's varied clinical presentation in Covid-19

Rajakannan Durairaj 
 Department of Ophthalmology, Eye Specialist, ESICPGIMSR, Chennai, Tamil Nadu, India

Correspondence Address:
Rajakannan Durairaj
191, 100 Feet bypass Road, Vijaya Nagar, Velachery. Chennai - 600 042, Tamil Nadu


A 52-year-old woman with Covid-19 on treatment presented with left eye pain and skin lesion on face. Diagnosed clinically as herpes zoster ophthalmicus in Covid-19. Confirmed by slitlamp biomicroscopy and fluorescein staining, Patient was treated for the same.In this brief report the author would like to insist that Covid-19 affects the immune system and thus increases the risk of herpes zoster. Patients require prompt diagnosis and treatment to prevent complications.

How to cite this article:
Durairaj R. Herpes zoster's varied clinical presentation in Covid-19.TNOA J Ophthalmic Sci Res 2022;60:210-211

How to cite this URL:
Durairaj R. Herpes zoster's varied clinical presentation in Covid-19. TNOA J Ophthalmic Sci Res [serial online] 2022 [cited 2022 Dec 1 ];60:210-211
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Full Text


Herpes zoster ophthalmicus is caused by a varicella-zoster virus. The virus remains dormant in dorsal root ganglia, which reactivates and spreads from the ganglia to its susceptible dermatome when the immune system is affected. Herpes zoster involves the ophthalmic division of trigeminal nerve and affects one or all other branches like lacrimal, supratrochlear and nasocilliary. Patients at risk of herpes zoster include elderly and immunocompromised hosts. Covid-19 is known to affect the immune system and may increase the risk of herpes zoster; only limited reports are available to confirm the association between Covid-19 and herpes zoster.[1] Here, we present a 52-year-old female Covid-19 patient with herpes zoster ophthalmicus.

 Case Report

A known case of Covid-19, who was a 52-year-old female, came to eye OPD with complaints of left eye pain, decreased vision and skin lesion over the left side of face for 4 days.

She is a known type 2 Diabetes mellitus patient on irregular treatment and past history of chickenpox.

On examination:-

On examination, skin lesion in V2 dermatome involving the tip of nose, vision in left eye 6/24, supra conjunctival congestion and decreased corneal sensation were found; corneal punctuate keratitis was confirmed with fluorescein staining, and patient had iriodocyclitis. Patient was treated with oral acyclovir 500 mg-5 times daily for 5 days and oral steroids, topical steroids and topical pupillary dilators were given for the sake of iridocyclitis to save the vision of the affected left eye.


Covid-19 primarily affects the pulmonary system; many extra pulmonary manifestations including cutaneous manifestation are exhibited by the patients. Herpes zoster is a viral infection caused by varicella-zoster virus. After a prior infection of chickenpox, dormant virus is activated any time during a lifetime of a patient. Herpes zoster ophthalmicus presents in V1 dermatome commonly. Herpes zoster ophthalmicus accounts nearly 15%–20% of herpes zoster.[1],[2]

Patients with immunocompromised state, old age, uncontrolled diabetes mellitus, HIV, cancer, steroid overuse and anti-cancer treatment can predispose to Herpes infection.[4],[5],[6]

Patients usually have flu-like illness before the onset of skin lesions. Conjunctival, corneal involvement and intra ocular complication are seen in herpes zoster involvement. They include epithelial or stromal keratitis, episcleritis, iritis, iridocyclitis, secondary glaucoma, neuro topic keratopathy and sixth nerve palsy.[3] Multiple dermatomal involvements may be observed-V1, V2 or both dermatome. V1 involvement is common; it includes forehead, upper lid, lower lid and central part of nose involving tip of the nose. V2 involvement includes maxillary region, upper face and lower face [Figure 1].{Figure 1}

Covid-19 decreases cell-mediated immunity by decreasing lymphocyte count and CD3+, CD4+, CD8+ T cells; thus, it increases the risk of herpes zoster. Physical and emotional stress associated with Covid-19 diagnosis may be a triggering factor for the development of herpes zoster.

Our patient is a known diabetic with Covid-related lymphopenia with psychological stress, which can be a cause of herpes zoster ophthalmicus.


Herpes Zoster may be a complication of Covid-19 and prompt diagnosis and treatment may prevent further progression and complication. Herpes zoster caused uveitis , corneal involvement and conjunctival involvement with regard to V1 dermatome. With regard to V2 dermatome, left side of face with the tip of nose involvement was there, hence rare presentation of herpes zoster ophthalmicus we have named inverse herpes zoster ophthalmicus in Covid-19 - a rare presentation.

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


Conflicts of interest

There are no conflicts of interest.


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