Orbital apex syndrome: an unusual complication of herpes zoster ophthalmicus

Abstract

BackgroundHerpes zoster ophthalmicus is defined as herpes zoster involvement of the ophthalmic division of the trigeminal nerve. Ocular involvement occurs in 20–70% of patients with herpes zoster ophthalmicus and may include blepharitis, keratoconjunctivitis, iritis, scleritis, and acute retinal necrosis. Orbital apex syndrome is a rare but severe ocular complication of herpes zoster ophthalmicus. We present here the first reported case of herpes zoster ophthalmicus complicated by orbital apex syndrome in a patient from Taiwan.Case presentationA 78-year-old man initially presented with patchy erythema and herpetiform vesicles on his left forehead and upper eyelid. He subsequently developed left-sided ocular complications including reduced visual acuity, anisocoria, ptosis, and complete ophthalmoplegia. Orbital magnetic resonance imaging (MRI) was performed on day 6 of admission to search for signs of the common causes of orbital apex syndrome such as hemorrhage, neoplasm, and cavernous sinus thrombosis. The MRI showed only orbital myositis and enhancement of the retro-orbital optic nerve sheath. The patient was diagnosed with herpes zoster ophthalmicus complicated by orbital apex syndrome. Although the ocular complications partially resolved after systemic antiviral therapy for 15 days and steroid therapy tapered over 12 weeks, there was residual limitation of abduction and paralysis of the left upper eyelid at follow-up at 180 days after the onset of symptoms. The orbital MRI findings at 180 days showed no significant changes compared with the MRI findings on day 6 of admission.ConclusionsPrimary care physicians should be aware of this rare but potentially sight-threatening complication of herpes zoster ophthalmicus. The appropriate therapy for orbital apex syndrome due to herpes zoster ophthalmicus and the potential outcomes of this condition require further investigation.

Concurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady

“…However, her cataract worsened, which may be a complication of uveitis or due to prolonged corticosteroid usage. She also had persistent anisocoria, as described in other reports [11], [13]. Our patient’s optic nerve function tests are within normal limits, and her optic disc remains pink.…”

“…Lee et al reported orbital myositis and enhancement of the retro-orbital optic nerve sheath on MRI in their case of orbital apex syndrome following herpes zoster ophthalmicus [13]. Diffuse inflammation of the orbital cavity, ocular muscles, and optic nerve on the affected side was also described by Shirato et al [11].…”

“…The mainstay of treatment of disseminated herpes zoster ophthalmicus is intravenous acyclovir and systemic corticosteroids [2], [9], [12], [13]. Infectious disease specialist and ophthalmologist play important roles in managing the disease.…”

Orbital Apex Syndrome Secondary to Herpes Zoster Ophthalmicus

“…In the present case report, MRI typically shows diffuse enhancement of the orbital apex involving the optic nerve, extraocular muscles are swollen, consistent with myositis (3,5,9,10,12,13).…”

The role of interleukin-10 gene polymorphism (rs 1800872) in the course of herpes zoster in adults

“…Recently, in addition to meningitis and meningoencephalitis, Ramsey-Hunt syndrome, namely a cervical node ganglionitis, has often begun to be diagnosed, development of which can lead to paralysis of facial muscles and reduced hearing abruption [27]. The development of ophthalmic herpes, in which a complete loss of vision is possible due to lesion of the optic nerve and its atrophy, deserves particular attention [28]. No less widespread complication of shingles is postherpetic neuralgia, which can persist for several months after regression of rash, and often leads to a reduction in ability, and in some cases, to a person's disability [29].…”