Journal List > J Korean Ophthalmol Soc > v.58(9) > 1010640

Park and Lee: An Unusual Case of Orbital Inflammation Preceding Herpes Zoster Ophthalmicus

Abstract

Purpose

To present a case of orbital inflammation and optic perineuritis preceding vesicular eruption in herpes zoster oph-thalmicus (HZO).

Case summary

An 84-year-old woman with a history of gall bladder cancer and hypertension complained of left periorbital eryth-ematous edema and discomfort. On examination, visual acuity was 20/25 bilaterally; no tenderness, proptosis or oph-thalmoplegia was observed. Pupils were equal, round, and reactive to light without relative afferent pupillary defects. Slit-lamp examination revealed severe conjunctival injection and chemosis without keratitis or uveitis. The remainder of the ocular exami-nation was unremarkable. Magnetic resonance imaging confirmed left-sided preseptal swelling with an enlarged left lacrimal gland, high signal intensity of the retrobulbar fat and optic nerve sheath. Systemic antibiotic therapy with steroids was started un-der a presumed diagnosis of idiopathic orbital inflammatory disease, but the clinical presentation was unresolved. After 2 days, vesicular lesions confined to the first division of the trigeminal nerve and pseudodendritic keratitis developed on the left side leading to a diagnosis of HZO. Treatment with acyclovir immediately resolved anterior segment inflammation and periorbital edema. While on therapy, visual acuity deteriorated to 20/125 and the pupil became dilated and unresponsive to light over a few days. All signs and symptoms of acute orbitopathy and postherpetic neuralgia had resolved 3 months later with the exception of pupil abnormality and visual acuity.

Conclusions

HZO may present with symptoms and signs of orbital inflammation and optic perineuritis even in the absence of a vesicular rash. Thus, HZO should be considered in the differential diagnosis of unexplained acute orbital syndromes.

References

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Figure 1.
Clinical photographs. (A) Left periorbital eryth-ematous edema without tenderness, proptosis or ophthalmoplegia was observed along with conjunctival injection and chemosis at initial presentation. (B) Four days after initial presentation, vesic-ular eruptions involving the first division of the trigeminal nerve on left side developed.
jkos-58-1099f1.tif
Figure 2.
Magnetic resonance imaging findings. (A) Axial and (B, C) coronal sections showed left-sided preseptal swelling, enlarged lacrimal gland (arrow) and high signal intensity of the retrobulbar fat and linear signal change of the optic nerve sheath.
jkos-58-1099f2.tif
Figure 3.
Fundus photographs and optical coherence tomography (OCT) image of the patient. (A) Fundus photograph of the left eye showed normal appearance of optic disc and posterior pole when the patient’s visual acuity deteriorated to 20/125 in spite of treatment. (B, C) Three months later, there was no optic disc pallor or significant peripapillary retinal nerve fiber layer defect on fundus photograph and OCT of the left eye. RNFL = retinal nerve fiber layer; OD = oculus dexter; OS = oculus sinister; TEMP = temporal; SUP = superior; NAS = nasal; INF = inferior; S = superior; N = nasal; I = inferior; T = temporal.
jkos-58-1099f3.tif
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