Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus

Sung Soo Hwang; Soo Jung Lee

doi:10.3341/jkos.2015.56.9.1467

Journal List > J Korean Ophthalmol Soc > v.56(9) > 1010096

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Hwang and Lee: Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus

Original Article

J Korean Ophthalmol Soc 2015;56(9):1467-1472.

Published online: 29 August 2015

DOI: https://doi.org/10.3341/jkos.2015.56.9.1467

Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus

Sung Soo Hwang, M.D., Soo Jung Lee, M.D., PhD

Department of Ophthalmology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea

Address reprint requests to Soo Jung Lee, MD, PhD Department of Ophthalmology, Inje University Haeundae Paik Hospital, #875 Haeun-daero, Haeundae-gu, Busan 48108, Korea Tel: 82-51-797-2310, Fax: 82-51-797-2321 E-mail: Kris9352@hanmail.net

∗ This study was presented as an e-poster at the 112th Annual Meeting of the Korean Ophthalmological Society 2014.

Received 9 January 201531 March 2015 Accepted 6 July 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To report a case of complete oculomotor nerve palsy with pupil involvement complicated by inflammation of the cav-ernous sinus. Complete resolution was obtained after 12 days of antiviral and steroid treatments.

Case summary

A 60-year-old male presented with edema and vesicles of the right upper eyelid. The patient had myalgia, cough, fever and headache 1 week earlier and was treated with conservative therapy. The patient received an antiviral agent (famciclovir 250 mg) twice a day and steroid agent (methylprednisolon 4 mg) once a day at the dermatology department for 1 week. The eyelid edema and vesicles improved. However, ptosis, ocular movement limitation, mydriasis of the right eye and dip-lopia occurred. Brain magnetic resonance imaging revealed hyperintensity in the right cavernous sinus with enhancement, im-plicating inflammation. The patient was diagnosed with right complete oculomotor nerve palsy with pupil involvement. An anti-viral agent (famciclovir 250 mg) three times a day and a steroid agent (prednisolone 40 mg) once a day were prescribed. From the next day, ptosis and ocular movement limitation improved and 12 days later, completely resolved.

Conclusions

Ocular movement limitation and mydriasis can be accompanied by herpes zoster ophthalmicus without uveitis and cerebral aneurysm. Administering active antiviral and steroid treatment to obtain rapid resolution is important.

Keywords: Cavernous sinus, Herpes zoster ophthalmicus, Oculomotor nerve palsy, Pupil, Steroid

References

1. Chung YR, Chang YH, Kim DH, Yang HS. Ocular manifestations of herpes zoster ophthalmicus. J Korean Ophthalmol Soc. 2010; 51:164–8.

2. Han JB, Kim TG, Jin KH. Three cases of pupil abnormality in her-pes zoster ophthalmicus. J Korean Ophthalmol Soc. 2013; 54:1452–7.

3. Cho GE, Choi KR, Jun RM. Herpes zoster ophthalmicus in patients younger than 50 years versus 50 years and older. J Korean Ophthalmol Soc. 2013; 54:19–25.

4. Bak CG, Jun DC, Kim JH. . A case of ophthalmoplegia caused by herpes zoster ophthalmicus. J Korean Neurol Assoc. 2002; 20:295–7.

5. Sanjay S, Chan EW, Gopal L. . Complete unilateral oph-thalmoplegia in herpes zoster ophthalmicus. J Neuroophthalmol. 2009; 29:325–37.

6. Ugarte M, Dey S, Jones CA. Ophthalmoplegia secondary to her-pes zoster ophthalmicus. BMJ Case Rep. 2010;Nov:2010. pii: bcr1220092532.

7. Delengocky T, Bui CM. Complete ophthalmoplegia with pupillary involvement as an initial clinical presentation of herpes zoster ophthalmicus. J Am Osteopath Assoc. 2008; 108:615–21.

8. Chaker N, Bouladi M, Chebil A. . Herpes zoster ophthalmicus associated with abducens palsy. J Neurosci Rural Pract. 2014; 5:180–2.

9. Czyz CN, Bacon TS, Petrie TP. . Isolated, complete paralytic mydriasis secondary to herpes zoster ophthalmicus. Pract Neurol. 2013; 13:183–4.

10. Quisling SV, Shah VA, Lee HK. . Magnetic resonance imaging of third cranial nerve palsy and trigeminal sensory loss caused by herpes zoster. J Neuroophthalmol. 2006; 26:47–8.

11. Reilly GS, Shin RK. Teaching Neuroimages: herpes zoster oph-thalmicus-related oculomotor palsy accompanied by Hutchinson sign. Neurology. 2010; 74:e65.

12. Yalcinbayir O, Yildiz M, Gunduz GU, Gelisken O. Herpes zoster ophthalmicus and lateral rectus palsy in an elderly patient. Case Rep Ophthalmol. 2011; 2:333–7.

13. Ryu WY, Kim NY, Kwon YH, Ahn HB. Herpes zoster oph-thalmicus with isolated trochlear nerve palsy in an otherwise healthy 13-year-old girl. J AAPOS. 2014; 18:193–5.

Figure 1.

Patient's photograph before retreatment. The patient had mild swelling and ptosis of the right upper eyelid. There was no exophthalmos.

Figure 2.

Nine cardinal gaze photos before retreatment. Nine cardinal gaze photographs shows limitation of adduction, elevation and depression of the right eye.

Figure 3.

Pupil size before retreatment. The pupils were anisocoric and unequally reactive to light. The reaction of the pupil of the right eye was sluggish, whereas the pupil of the left eye was brisk. In bright light, the pupils were 6 mm (A) in the right eye and 2 mm (B) in the left eye.

Figure 4.

Brain magnetic resonance image. (A) FLAIR image and (B) contrast enhanced T1 fast field echo image reveals hyper-intensity in the superolateral portion of the right cavernous sinus (arrow) and encagement of the third nerve is observed (arrowheads). FLAIR = fluid attenuated inversion recovery.

Figure 5.

Nine cardinal gaze photos after retreatment. Twelve days after retreatment, nine cardinal gaze photographs shows no ocu-lar movement limitation of the right eye. The ptosis of the right eye resolved completely.

Figure 6.

Pupil size after retreatment. Twelve days after retreatment, pupil size of (A) right eye and (B) the left eye was equal and 2 mm.

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