Painful ophthalmoplegia with simultaneous orbital myositis, optic and oculomotor nerve inflammation and trigeminal nucleus involvement in a patient with herpes zoster ophthalmicus

The Use of Systemic Steroids in the Treatment of Herpes Zoster Ophthalmicus-Related Ophthalmoplegia: Case Report and Case Meta-analysis

PURPOSE

The role of systemic steroids in the treatment of ophthalmoplegia in the setting of herpes zoster ophthalmicus (HZO) is controversial. We conducted a case report-based meta-analysis to investigate the role of systemic steroid in the recovery of efferent dysfunctions in HZO.

DESIGN

Case-report based meta-analysis.

METHOD

We report a case of herpes zoster ophthalmicus-related ophthalmoplegia (HZORO) in which systemic steroid led to complete resolution of external ophthalmoplegia. We further identified subjects from published cases of HZO-related ophthalmoplegia by searching PubMed and Google Scholar, which elicited 42 articles (49 cases) after excluding those younger than 18 years or with incomplete follow-up data. With the present case, a total of 50 cases are included in the analysis. Main outcome measure is the recovery of efferent dysfunction at the last known follow-up, coded as 1 for complete recovery or 0 for noncomplete recovery. We performed multivariable linear regression and Cox proportional hazards analysis to determine the contribution of steroid duration on the status of complete recovery.

RESULTS

Multivariable linear regression showed significant association between duration of steroid treatment and status of complete recovery (P < .001). Cox proportional hazards analysis showed a hazard ratio of 1.1 (P = .04), indicating that longer treatment duration increased chance of complete recovery. Age, gender, and initial steroid dose did not contribute significantly to recovery status.

CONCLUSION

Our meta-analysis suggests that extended steroid taper may aid the recovery of ophthalmoplegia in the setting of HZO and should be investigated further in the future.

Isolated optic neuritis with a concurrent abnormal trigeminal nucleus on imaging: case report of a rare complication of herpes zoster ophthalmicus

Background

Herpes zoster ophthalmicus (HZO) is an inflammation related to reactivation of the latent varicella zoster virus (VZV), involving the ophthalmic branch of the trigeminal nerve. Optic neuritis (ON), a rare ocular complication following HZO, has been reported in 1.9% of HZO-affected eyes. Most previous cases occurred simultaneously with other ocular complications, especially orbital apex syndrome. Moreover, detailed magnetic resonance imaging (MRI) with diffusion weighted imaging of the optic nerve and trigeminal nucleus in HZO-related ON has been rarely reported. We report a case of postherpetic isolated ON with a concurrent abnormal trigeminal nucleus on imaging.

Case presentation

A healthy 58-year-old female presented with sudden painful visual loss in her right eye for 2 days. Four weeks before the presentation, her right eye was diagnosed with HZO, and she received intravenous acyclovir for 10 days. Ophthalmic examination revealed a visual acuity of light perception and 20/20 in the right and left eyes, respectively. A relative afferent pupillary defect was present in the right eye. Neurological examination was significant for hypoesthesia in the area of the HZO. A clinical diagnosis of HZO-related right retrobulbar ON was made, and other causes of atypical ON were excluded. MRI showed enhancement and restricted diffusion of the right-sided optic nerve with linear hyperintense T2 of the right-sided spinal trigeminal nucleus and tract (STNT) along the brainstem. She received 14 days of intravenous acyclovir and 5 days of methylprednisolone. Both were switched to an oral route for 2 months. After the completion of treatment, the visual acuity was counting fingers and 20/20 in the right eye and left eye, respectively. Stable brainstem STNT abnormalities and resolution of ON were found radiologically.

Conclusions

Isolated ON is a rare ocular complication following HZO. An abnormal high signal of STNT on a T2 weighted image may be present, which may be a clue for VZV-associated complications, such as HZO-related ON, especially in cases lacking an obvious history of HZO or other concomitant ocular complications. Prompt treatment with both acyclovir and corticosteroids should be started. Restricted diffusion of the optic nerve may be a predictor for poor visual recovery.

Herpes Zoster Ophthalmicus With Orbital Findings Preceding Skin Rash

The authors describe 2 patients who presented with orbital findings and later developed vesicular lesions that were positive for varicella zoster virus and consistent with Herpes Zoster ophthalmicus. One case is the first to involve dacryoadenitis and orbital myositis preceding disseminated Herpes Zoster. In the other case, a patient developed zoster orbital syndrome leading to elevated intraocular pressure, loss of vision, and afferent pupillary defect. Canthotomy and cantholysis were required to restore vision. In both cases, the orbital syndrome developed prior to the vesicular rash. These cases highlight the need to consider Herpes Zoster ophthalmicus in patients with orbital syndrome not responding to conventional treatment.

Herpes zoster ophthalmicus and strabismus: a unique cause of secondary Brown syndrome

Herpes zoster ophthalmicus can be associated with a variety of ocular and visual sequelae, including isolated or even multiple cranial neuropathies, potentially affecting the oculomotor, trochlear, or abducens nerves. We report a case of a secondary Brown syndrome following resolution of a unilateral isolated trochlear nerve palsy associated with herpes zoster ophthalmicus in an immunocompetent 57-year-old man.

Shingles as the underlying cause of orbital myositis in an adolescent: A case report

PURPOSE

Orbital myositis is characterized by pain with eye movements, gaze restriction, diplopia, and enlargement of extraocular muscles on imaging. Varicella zoster virus (VZV) is an extremely rare cause of the disease in the elderly and has never been reported in a patient younger than forty-five years old such as the adolescent described herein. We present this case to raise awareness of an entity that will likely become more prevalent due to current vaccine strategies.

OBSERVATION

We present the case of a 13-year-old girl with VZV-associated orbital myositis and meningitis that had a quick and complete recovery following IV acyclovir and oral steroids.

CONCLUSIONS AND IMPORTANCE

In conclusion, orbital myositis is an extremely rare complication of facial VZV infections. Our case highlights the importance of prompt detection and treatment in the pediatric population.