A 57-year-old female came to the ophthalmology department complaining of decreased visual acuity. According to patient history and previous medical records, the patient had been known to suffer from trigeminal neuralgia for several decades. She had previously undergone a central nervous system examination to determine the etiologic lesion of trigeminal neuralgia, but was informed of the incidental finding of an epidermoid cyst impinging on the trigeminal nerve.
She underwent brain surgery for partial removal of the epidermoid tumor. After the brain surgery, her trigeminal neuralgia had subsided for several years but had reappeared, causing her to visit the anesthesiology clinic for treatment of the debilitating pain.
She had undergone right trigeminal nerve block (percutaneous block of maxillary, mandibular nerve with alcohol and infraorbital nerve block) for pain treatment. Under the fluoroscopic view, for maxillary nerve block, a needle tip can be located right lateral to the foramen rotundum and pterygopalatine fossa; for mandibular nerve block, a needle tip can be placed at the midportion of the foramen ovale.
Her pain had decreased with right-side facial numbness. After 3 days posttrigeminal block, she presented with vesicles over the right lower lid and cheek. A clinical diagnosis of herpes zoster infection of the maxillary branch of the trigeminal nerve was made. She was started on oral famciclovir 250 mg every 8 h. She noticed progressively decreasing visual acuity around 10 days after trigeminal block, during her treatment with famciclovir.
She was referred to the ophthalmology department of St. Vincent's Hospital. She had never been to an ophthalmologist before this event. On initial examination, her visual acuity was 0.06 (0.25 with pin-hole correction) in the right eye and 0.16 (0.8 x -3.25 Dsph; -0.50 Dcyl A x 94) in the left eye. Intraocular pressure was 13 mm Hg (right eye)/10 mm Hg (left eye). At slit lamp examination, her cornea showed an irregular epithelial defect with Descemet's membrane folding (Fig. 1).
There was no cell reaction in the anterior chamber. Clinically, she was then diagnosed with neurotrophic keratitis by trigeminal block, and less likely herpes zoster keratitis from herpes zoster ophthalmicus involving the ophthalmic branch of the trigeminal nerve.
She was treated with oral famciclovir 750 mg per day, topical 3% acyclovir ointment 5 times per day, and hourly Solcoseryl eye drops (1.4%) and 50% autologous serum eye drops. She showed fast recovery of the right cornea with epithelial closure and her visual acuity was increased to 0.5 within 3 days of treatment.
However, 2 days after epithelial healing, she reappeared with decreased visual acuity of the right eye. Her visual acuity decreased again to 0.02 and the cornea showed central and peripheral geographic epithelial defect with Descemet's folding (Fig. 2).
Along with the previous treatment of oral and topical antiviral and lubrication with Solcoseryl and autologous serum, her lower lacrimal punctum was temporarily occluded with a punctal plug and she was on hourly 5% albumin eye drops. Varicella zoster virus PCR was also done. An HIV serological test was done and the result was negative.
Her cornea showed slower recovery in epithelial healing. Five days after the second outbreak of epithelial keratitis, the epithelial defect slightly decreased but the Descemet's folding remained. Her visual acuity was 0.15.
One month after block, her cornea showed central opacity and faint peripheral linear epithelial irregularity. Endothelial cell damage was observed compared with the contralateral eye. The scar on her cheek remained (Fig. 3).