Nonarteritic Anterior Ischemic Optic Neuropathy following Herpes Zoster Ophthalmicus and Steroid-Related Intraocular Pressure Spike

Abstract

A 61-year-old woman presented with sudden vision loss from a left anterior optic neuropathy in the context of severely elevated intraocular pressure after starting topical steroids for anterior uveitis related to herpes zoster ophthalmicus (HZO). The strong temporal relationship between the vision loss and elevated IOP suggested the vision loss was related to nonarteritic anterior ischemic optic neuropathy (NAION). Anterior chamber paracentesis did not detect varicella zoster virus (VZV) and magnetic resonance imaging of the orbits was normal. Her vision remained stable and the optic disc edema resolved within 3 months. The occurrence of NAION following an acute elevation of intraocular pressure (IOP) is well-documented in the context of surgical procedures, glaucoma, uveitis and trauma. This case indicates that not every optic neuropathy in close temporal relationship with HZO is directly attributable to the virus. NAION may also occur after steroid-related IOP spikes and ophthalmologists should ensure that patients on topical steroids are closely monitored for ocular complications.

A case of herpes zoster ophthalmicus with optic neuritis of the total length of the optic nerve in the orbital space and ischemic optic neuropathy

“…The rate of certain ocular complications caused by herpes zoster ophthalmicus is reportedly about 50%, and among them, the rate of optic neuropathy is <0.5%. 1 , 2 Ischemic optic neuropathy is even rarer, and in our investigation, we found several reports of anterior ischemic optic neuropathy and posterior ischemic optic neuropathy shortly after the onset of herpes zoster ophthalmicus 3 , 4 , 5 , 6 , 7 , 8 , 9 , however, there have been no such reports from Japan.…”

“…There have been a few reports concerning ischemic optic neuropathy after the onset of herpes zoster ophthalmicus. 3 , 4 , 5 , 6 , 7 , 8 , 9 Some of these reports have speculated that these conditions are part of VZV vasculopathy, and VZV antigens were reportedly found in a temporal artery biopsy specimen. 4 , 5 , 6 In our case, the presence of temporal arteritis could not be confirmed, and the presence of other obstructive vasculitis was unable to be objectively determined.…”