Sandy Zhou Wenting, Amy Chan MInhui, Chee Fang Chin
Purpose: To describe the clinical features and radio- graphic ﬁndings of patients with herpes zoster ophthalmicus (HZO) and associated acute ophthalmoplegia.
Methods: Medical records of 4 cases and existing literature on HZO with acute ophthalmoplegia were reviewed.
Results: Three males and one female with a median age of 64 years presented with HZO. Three of them were diabetic, and one of them had systemic lupus erythematosus. The average onset of acute ophthal- moplegia from initial presentation of HZO was
16 days (range 7-35 days). Clinical ﬁndings of ophthalmoplegia included oculomotor nerve palsy (75%), abducens nerve palsy (75%) and a mixture of both (50%). MRI features demonstrated enhance- ment of the cavernous sinus (100%), orbital apex (75%), superior orbital ﬁssure (50%) or myositis (25%). Interestingly, one patient was found to have enhancement along the route of the trigeminal nerve extending from the brainstem. 3 patients had lum- bar puncture, which showed pleocystosis with 1 of them having positive varicella zostoer virus (VZV) DNA. Treatment with intravenous acyclovir was administered in all patients and in 2 cases systemic corticosteroids were also given. Ophthalmoplegia improved in all patients over weeks to months.
Conclusions: Ophthalmoplegia is not an unusual complication of HZO. Systemic diseases such as dia- betes or immunosuppression predispose the patients with HZO to central nervous system involvement. Cavernous sinus enhancement is a common radio- graphic feature of HZO related ophthalmoplegia. Improvement of symptoms and signs with systemic antiviral therapy can be expected. The role of sys- temic steroids in treatment of orbital disease is yet to be determined.