A rare case of orbital apex syndrome with herpes zoster ophthalmicus in a human immunodeficiency virus-positive patient

Saxena, Rohit; Phuljhele, Swati; Aalok, Lalit; Sinha, Ankur; Menon, Vimla; Sharma, Pradeep

doi:10.4103/0301-4738.71708

Cited by 27 publications

(22 citation statements)

References 9 publications

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“…Although systemic acyclovir and prednisolone 30 mg slightly improved the visual acuity and disturbances of eye movements, the ptosis, anisocoria, and partial ophthalmoplegia did not improve. Saxena et al12 also reported a case of human immunodeficiency virus associated with herpes zoster ophthalmicus. A 29-year-old woman developed severe anterior uveitis, optic neuritis, complete ptosis, and ophthalmoplegia due to myositis 14 days after the onset of a facial rash.…”

Section: Discussionmentioning

confidence: 98%

Orbital apex syndrome associated with herpes zoster ophthalmicus

Kurimoto¹,

Tonari²,

Ishizaki³

et al. 2011

OPTH

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We report our findings for a patient with orbital apex syndrome associated with herpes zoster ophthalmicus. Our patient was initially admitted to a neighborhood hospital because of nausea and loss of appetite of 10 days’ duration. The day after hospitalization, she developed skin vesicles along the first division of the trigeminal nerve, with severe lid swelling and conjunctival injection. On suspicion of meningoencephalitis caused by varicella zoster virus, antiviral therapy with vidarabine and betamethasone was started. Seventeen days later, complete ptosis and ophthalmoplegia developed in the right eye. The light reflex in the right eye was absent and anisocoria was present, with the right pupil larger than the left. Fat-suppressed enhanced T1-weighted magnetic resonance images showed high intensity areas in the muscle cone, cavernous sinus, and orbital optic nerve sheath. Our patient was diagnosed with orbital apex syndrome, and because of skin vesicles in the first division of the trigeminal nerve, the orbital apex syndrome was considered to be caused by herpes zoster ophthalmicus. After the patient was transferred to our hospital, prednisolone 60 mg and vidarabine antiviral therapy was started, and fever and headaches disappeared five days later. The ophthalmoplegia and optic neuritis, but not the anisocoria, gradually resolved during tapering of oral therapy. From the clinical findings and course, the cause of the orbital apex syndrome was most likely invasion of the orbital apex and cavernous sinus by the herpes virus through the trigeminal nerve ganglia.

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Section: Discussionmentioning

confidence: 98%

Orbital apex syndrome associated with herpes zoster ophthalmicus

Kurimoto¹,

Tonari²,

Ishizaki³

et al. 2011

OPTH

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“…In our case adduction and ptosis resolved but abduction deficit persisted. Residual deficits in extraocular motility have been reported in literature [7][8][9][10]. Also, the optic nerve function did not improve.…”

Section: Discussionmentioning

confidence: 61%

“…In previous studies, most patients were of elderly age group (>60 years), with only 1 case of an immune-deficient 29-year-old being reported [9]. In our case the presentation was severe inspite the fact that patient was immune-competent.…”

Section: Discussionmentioning

confidence: 64%

A Rare Case of Orbital Apex Syndrome in Herpes Zoster Ophthalmicus

Kalamkar¹

2016

JCDR

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A 65-year-old male presented with a 10 day history of swelling of upper and lower lids of right eye with blurring of vision and pain. He had vesicular rash on tip and side of nose.Examination revealed vesicular rash on tip and side of nose which was resolving and had started to crust. There was severe periocular congestion, conjunctival chemosis with ptosis. Ocular motility was limited in all gazes indicating total external ophthalmoplegia [ Right eye slit-lamp examination revealed superficial punctate keratitis, anterior uveitis (Anterior Chamber cells and fresh keratic precipitates) and senile cataract. Corneal sensations were diminished. Relative Afferent Pupillary Defect (RAPD) was present in the right eye. Intraocular Pressure (IOP) was not possible due to severe lid congestion at initial examination. Fundus examination showed a myopic disc with peripapillary atrophy and chorioretinal degeneration. There were no signs of inflammation in the posterior segment. Left eye had a normal anterior segment other than senile cataract. Left eye posterior segment also revealed a myopic fundus.Blood investigations were within normal range (complete blood count, ESR). ELISA for HIV was negative.Magnetic Resonance Scanning (MRS) revealed enhancing soft tissue thickening of right eye periocular tissue with oedema of muscle cone but no enhancement of optic nerve in retro-bulbar or intraorbital region [ ABStRACtOrbital Apex Syndrome (OAS) is a rare complication of Herpes Zoster Ophthalmicus (HZO). We are reporting a case of 65-yearold male who developed OAS following HZO. Patient presented with vesicular rash in the typical dermatomal distribution, severe periocular congestion and limited ocular motility in all gazes along with loss of vision. Soft tissue inflammation improved within 4 weeks of initiation of treatment while ocular motility slowly improved over 3 months. Patient did not gain vision despite receiving systemic steroids and systemic anti-viral medication. Variable improvement in ocular motility and visual function in our patient points towards multiple mechanisms involved in pathogenesis of this disease, some of which are yet to be understood. Based on the presence of vesicular rash in typical location with total external ophthalmoplegia and optic nerve involvement, diagnosis of Herpes Zoster Ophthalmicus (HZO) with Orbital Apex Syndrome (OAS) was made.Patient was admitted and started on injection I.V. Methylprednisolone (1 gm per day for 3 days) along with oral acyclovir 800mg 5 times per day. Acyclovir ointment and cycloplegics were also started topically. After 3 days of I.V. Methylprednisolone, oral steroids were started and slowly tapered over 2 months.On day 2, patient developed an epithelial defect (dimensions being 3mm by 4mm) which healed by day 5. By 7 th day anterior chamber reaction resolved and cornea cleared. Lid oedema and conjunctival chemosis significantly reduced by the end of 1 st week of starting treatment. Ptosis resolved completely by day 14. Ocular motility started improving after 1 st we...

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“…The aetiologies are quite varied and include infections, neoplasm, TAO, granulomatous, iatrogenic mucocele and vascular lesions. [4][5][6][7][8] In our case no mass lesions or localised collections were noticed on imaging. MRI showed inflammation and swelling of ocular muscles and optic nerve.…”

Section: Discussionmentioning

confidence: 79%

Thyroid-Associated Orbitopathy

2018

Encyclopedia of Ophthalmology

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SUMMARYThyroid-associated orbitopathy (TAO) is a self-limiting auto-immune condition usually associated with Grave's disease. It is characterised by ocular pain, eyelid swelling, chemosis, proptosis and keratopathy. As the mechanism for ophthamoplegia and optic neuropathy is the orbital swelling leading to mechanical restriction of ocular muscles and compression of optic nerve, one expects proptosis rather than ptosis in TAO. We describe a case of a young adult woman who presented with acute onset restriction of movement along with partial ptosis and severe diminution of vision in left eye. The MRI of orbit revealed significant swelling of recti along with signal alteration consistent with TAO. The radioisotope thyroid scan revealed thyroiditis, and thyroid peroxidase (TPO) antibody was significantly high; hence, the diagnosis of Hashimoto thyroiditis was considered. A course of intravenous methylprednisolone followed by oral steroid was administered, which produced marked improvement in vision and extraocular movement. BACKGROUND

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A rare case of orbital apex syndrome with herpes zoster ophthalmicus in a human immunodeficiency virus-positive patient

Cited by 27 publications

References 9 publications

Orbital apex syndrome associated with herpes zoster ophthalmicus

Orbital apex syndrome associated with herpes zoster ophthalmicus

A Rare Case of Orbital Apex Syndrome in Herpes Zoster Ophthalmicus

Thyroid-Associated Orbitopathy

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