Herpes zoster optic neuropathy (HZON) is a rare manifestation of herpes zoster ophthalmicus (HZO). It is a potentially blinding condition. We report a case of an immunocompetent patient with HZON following keratouveitis during the course of treatment. A 33-year-old gentleman presented with left eye (LE) worsening of visual acuity (6/9 reduced to 6/24) despite on treatment for HZO keratouveitis. It was associated with pain on ocular movement and central scotoma. He was on systemic acyclovir and topical corticosteroids prior to current complaint. Fundoscopy showed left optic disc swelling with impaired optic nerve functions. Diagnosis of left optic neuritis secondary to HZO was established in view of close temporal relationship with occurrence of cutaneous herpes zoster. Systemic corticosteroids was commenced. The patient had obtained good visual outcome at two months. Early referral for ophthalmology assessment is crucial to establish diagnosis of HZON and prompt initiation of treatment may preserve vision.

Rheumatoid arthritis (RA) is a multisystemic autoimmune disease which can be associated with visual threatening ocular manifestations. Common ocular associations with RA include necrotising scleritis and peripheral ulcerative keratitis (PUK). Optic nerve involvement otherwise is uncommon, especially as a presenting feature of RA. We report a rare case of recurrent bilateral retrobulbar optic neuritis (ON) with progressive visual deterioration as an early manifestation of seronegative RA. This case posed diagnostic and management challenges due to its unusual presentation and initially inconclusive investigations. The patient was diagnosed with seronegative RA three years after the first eye presentation. Her RA disease activity score (DAS-28) improved after treatment with a disease-modifying anti-rheumatic drugs (DMARDs), and her ON attacks have been controlled since then. However, her visual acuity, visual field and colour vision remained poor after multiple ON attacks. Multidisciplinary care is key to managing such a patient’s condition and its potential disease complications.