Introduction

Acute herpetic neuralgia (AHN) is severe debilitating pain accompanying an acute herpes zoster infection that may persist for up to thirty days after onset.

Subacute herpetic neuralgia refers to the pain that persists beyond the acute period but resolves within three months of onset.

Post-herpetic neuralgia is the experience of pain beyond three months to years after the onset of a herpes zoster rash.

We present the case of a palliative inpatient admitted for heart failure with debilitating severe right eye pain and inability to open the eye secondary to ophthalmic herpetic neuralgia for one month.

A supraorbital and supratrochlear nerve block with triamcinolone was performed, and successfully brought symptomatic relief until the patient was discharged to hospice eleven days later. He continued to have pain relief until his death two weeks after discharge.

Case Report

69 yo M with a complex PMH was transferred to our institution for management of profound cardiogenic shock. Weeks prior, he had been hospitalized due to a right acute ophthalmic herpes zoster infection. During his admission at our hospital, he continued to experience severe right eye pain secondary to the herpes zoster involvement refractory to medical management.

PE: unable to open his right eye due to intense pain, the focal point of which he identified to be the skin of his right upper eyelid.

Procedure: Landmark-guided supraorbital and supratrochlear nerve block with 2mL of 0.25% bupivacaine mixed with 10mg of preservative-free dexamethasone near the supraorbital foramen. The patient immediately reported a significant improvement in his pain, and he was able to open his right eye for the first time in a month. His pain scores were consistently reported as 2/10 post-block. Analgesia lasted about 30 hours.

Repeat SON & STN block, but this time with 2mL of 0.25% bupivacaine and 1mL of triamcinolone. The next day, the patient had a pain score of 0/10, could keep his right eye open, and was not experiencing pain near the block site at the supraorbital foramen. His pain scores remained 0/10 for the subsequent five days of his admission.

Once the patient was medically stabilized, he was discharged from our institution and returned home to hospice care. He was lost to follow up as he passed away two weeks later.

Discussion

Initially, the consultation was for Gasserian ganglion ablation. However, this is not a procedure that is performed by our acute pain service or our interventional pain physicians in an inpatient setting (our acute pain service is made up of regional and acute pain as well as interventional pain fellowship-trained faculty).

The supraorbital and supratrochlear nerves are the terminal sensory branches of the ophthalmic nerve (CN V1); they exit the frontal bone through the supraorbital foramen, providing sensory input to the forehead, upper eyelid, and anterior scalp. Supraorbital and supratrochlear nerve radiofrequency ablations have been compared to Gasserian ganglion ablations for the treatment of herpetic neuralgia and have demonstrated similar analgesic effects.

Side effects specific to performing cyroneurolysis or injecting triamcinolone into the face. Cryoneurolysis can cause skin necrosis and hair loss at the eyebrows. Triamcinolone can cause thinning of the skin, which can lead to dimpling of the skin, as well as discoloration.

Our patient’s priority was symptomatic pain relief from AHN, so he accepted all procedural and medication-specific risks.