Intended for healthcare professionals

Endgames Case Review

Photophobia and a painful rash

BMJ 2016; 353 doi: (Published 13 June 2016) Cite this as: BMJ 2016;353:i3221
  1. Andrew Malem, specialist trainee year 3, ophthalmology1
  1. 1Eye Department, Queen Alexandra Hospital, Portsmouth PO6 3LY, UK
  1. Correspondence to: A Malem andrew.malem{at}

A 62 year old woman presented to eye casualty with a 10 day history of a left sided headache. Two days after her headache started she developed a painful and pruritic left sided rash. During the 24 hours before presentation, her left eye had become injected, painful, and photophobic.

On examination she had a well demarcated, unilateral area of erythematous and mildly oedematous skin, which extended from her left upper lid up across her forehead. Within this area were discrete tender scabbed lesions, which extended back into her hairline (fig 1). She had no lesions on the tip of her nose or in her auditory canal. No lesions crossed the midline to the right side of her forehead or scalp.

Fig 1 Left side scabbed skin lesions respecting the midline with associated left lid swelling and conjunctival injection

Ocular examination showed an unaided visual acuity of 6/6 in the right eye and 6/9 in the left eye. Ocular motility was full. Intraocular pressures were 10 mm Hg in the right eye and 12 mm Hg in the left. Her left cornea was clear and did not stain with fluorescein, while her conjunctiva was diffusely injected. Slit lamp examination of her left anterior chamber showed 1+ for cells and flare. Dilated funduscopy showed a clear vitreous and healthy fundus. Her right ocular examination was normal.


  1. What is the most likely diagnosis?

  2. How is the diagnosis confirmed?

  3. How is the condition managed?

  4. What complications might occur?


1. What is the most likely diagnosis?

Short answer

Left herpes zoster ophthalmicus (HZO) with associated anterior uveitis.


HZO occurs when latent varicella zoster virus (VZV), residing in the ganglion of the trigeminal nerve, reactivates and affects the ophthalmic nerve (V1). Primary infection with VZV commonly occurs in childhood as chickenpox. Anterior uveitis occurs in 40-50% of all cases of HZO.1

The …

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