Herpes Zoster Ophthalmicus Complicating Nasal Forehead Flap Reconstruction

There have been three reports (a total of eight cases) of Herpes Zoster (HZ) complicating plastic surgery procedures of the head and neck ^1,2 .  None of these cases had significant ophthalmologic complications.  This is the first report of HZ Ophthalmicus associated with ocular complications developing during the course of a staged nasal reconstruction with a paramedian forehead flap.  One week after an intermediate-stage thinning of the flap, the patient presented with erythema of the flap, the pedicle and the adjacent upper eyelid.  Cellulitis was diagnosed and the patient initially treated with oral antibiotics.  Her optometrist added antibiotic eye drops.  She was referred to an ophthalmologist who continued treatment for pre-septal cellulitis.

As her eye irritation and headaches worsened, vesicles appeared on her flap and forehead, while the adjacent nasal skin was spared (V₁ involved-V₂ uninvolved).  The diagnosis of Herpes Zoster Ophthalmicus was made.  The patient proceeded to develop HZ keratoconjunctivitis, uveitis, and optic neuritis.  Her visual acuity deteriorated.  Emergent hospitalization and treatment with intravenous acyclovir prevented significant permanent visual impairment.  She ultimately required replacement of her ocular lens.

Among cases of Herpes Zoster, involvement of the eye is uncommon, occurring in only nine percent of cases in a large cohort ³.  Plastic surgeons need to be aware of the possibility of the onset of shingles when a patient develops worsening post-operative erythema and edema that does not respond to antibiotics.