Herpes Zoster Optic Neuropathy
Herpes zoster ophthalmicus can produce profound vision loss through overlapping infectious, inflammatory, and vascular mechanisms. We present an immunosuppressed patient with lupus nephritis receiving mycophenolate and systemic corticosteroids who developed a severe unilateral facial rash followed by rapidly progressive monocular vision loss to no light perception. Cutaneous lesion PCR was positive for varicella-zoster virus DNA, while MOG-IgG, AQP4-IgG, syphilis, Lyme disease, sarcoidosis, ANA, and ANCA testing were unrevealing. Orbital MRI demonstrated an optic-nerve abnormality consistent with optic neuropathy, raising concern for HZO-associated optic neuropathy with possible inflammatory and ischemic/NAION-like components. This case highlights the need to distinguish direct viral neuritis or perineuritis, immune-mediated inflammation, and VZV vasculopathy, as these processes may coexist and influence treatment. Urgent evaluation should localize the lesion and assess for retinal, orbital, CNS, and vascular involvement using MRI, targeted serum studies, CSF testing when indicated, and ocular-fluid testing for suspected intraocular viral disease. Prompt systemic antiviral therapy is foundational; corticosteroids may be considered after antiviral coverage when inflammation is compelling, while plasma exchange should be reserved for selected cases in which immune-mediated optic neuritis remains plausible.
Presentation Date: 08/13/2026
Issue Date: 08/21/2026
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