Abstract
RATIONALE: Herpes zoster ophthalmicus (HZO) occurs after the reactivation of latent varicella-zoster virus (VZV) present within the sensory spinal or cerebral ganglia and sometimes causes ocular inflammatory diseases, including neovascular glaucoma (NVG), which is one of the most devastating sequelae of virus-associated uveitis. In NVG, the synechial angle ultimately closes due to the contraction of proliferating myofibroblasts, which often requires glaucoma filtration surgery, including Ahmed glaucoma drainage device implantation, to maintain optimum intraocular pressure (IOP). Although tube exposure from the conjunctiva is a complication of glaucoma implant surgery, a case in which a glaucoma tube implant was repeatedly exposed due to masked HZO in a postoperative eye with NVG has not been reported. PATIENT CONCERNS: A 72-year-old male with NVG in his left eye ultimately underwent Ahmed glaucoma valve implantation with sulcus fixation for uncontrolled IOP. Before surgery, acyclovir ophthalmic ointment had been applied to treat a suspected VZV infection, but the regimen was discontinued because an aqueous humor sample tested negative for VZV according to polymerase chain reaction. Postoperatively, the patient's IOP dramatically decreased without any need for glaucoma eye drops. However, the tube was exposed when the overlying conjunctiva and allogeneic scleral grafts disintegrated. DIAGNOSES: Although the tube was covered with different types of tissues, including an allogeneic corneal graft and an autogenous conjunctival graft from the same eye, the grafts completely disintegrated again. Covering the tube with another allogeneic corneal graft and an autogenous free conjunctival graft from the contralateral eye also failed, with gradual disintegration of these tissues. During the observation period, severe HZO with Hutchinson sign and clearly demarcated pseudodendritic corneal ulceration were noted. INTERVENTIONS: After thorough consideration, we cut and removed the tube to avoid possible scleral perforation due to prolonged inflammation. OUTCOMES: Fortunately, the patient's IOP was controlled by resuming the continuous daily application of antiviral ointment and repeatedly injecting anti-vascular endothelial growth factor for rubeosis regularly afterward. LESSONS: The possibility of VZV reactivation should always be considered in cases of tube exposure due to an unknown cause after Ahmed valve implantation in an eye with NVG.