Herpes Zoster Ophthalmicus Associated Vasculopathy Presenting as Concurrent Cilioretinal Artery Occlusion, Central Retinal Vein Occlusion, and Optic Neuropathy

Purpose: To report a case of concurrent cilioretinal artery occlusion, central retinal vein occlusion (CRVO), and optic neuropathy associated with herpes zoster ophthalmicus (HZO) in an immunocompetent young adult. Methods: Retrospective review of clinical records and color fundus, fundus autofluorescence, fluorescein angiography, optical coherence tomography, and Magnetic Resonance Imaging (MRI) images. Results: A 30-year-old immunocompetent patient presented with a V1 vesicular rash followed by profound vision loss. Fundus examination demonstrated marked ischemia in the macula and findings consistent with CRVO, while fluorescein angiography additionally revealed delayed cilioretinal artery perfusion. MRI showed enlarged optic nerve and sheath enhancement, suggestive of optic nerve involvement. The patient was treated with intravenous acyclovir and systemic corticosteroids. Despite treatment, vision remained poor. Follow-up examination demonstrated optic nerve pallor and inner retinal atrophy within the cilioretinal artery territory. Discussion: HZO-associated vasculopathy can involve retinal arterial, retinal venous, and optic nerve circulations simultaneously, resulting in severe and irreversible vision loss. Recognition of vision loss that appears disproportionate to retinal vein occlusion findings should prompt evaluation for concurrent ischemic complications and initiation of appropriate antiviral therapy, while the role of adjunctive corticosteroids remains uncertain