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Li JXL, Tong JY, Tumuluri K. Orbital apex syndrome in herpes zoster ophthalmicus clinical features, treatment and outcomes: a case series and literature review. Orbit 2023:1-6. [PMID: 38108804 DOI: 10.1080/01676830.2023.2295473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/09/2023] [Indexed: 12/19/2023]
Abstract
Orbital Apex Syndrome (OAS) complicating Herpes Zoster Ophthalmicus (HZO) is associated with significant visual impairment. We present four patients with HZO OAS, to highlight clinical features and outcomes in order to promote earlier recognition and management of this potentially sight-threatening complication. CT and MRI imaging findings included expansion and enhancement of extraocular muscles and intraconal fat and involvement of the orbital apex and cavernous sinus. All patients received systemic steroid and antiviral therapy, but a standardised dosage and duration of treatment remains to be defined. Final visual acuity and extraocular motility outcomes were variable.
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Affiliation(s)
- Jessica X L Li
- Department of Ophthalmology, Liverpool Hospital, Liverpool, Australia
| | - Jessica Y Tong
- Department of Ophthalmology, The Royal Adelaide Hospital, Adelaide, Australia
| | - Krishna Tumuluri
- Department of Ophthalmology, Liverpool Hospital, Liverpool, Australia
- Save Sight Institute, University of Sydney, Camperdown, Australia
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Plasencia M, McQueen BR. Orbital Apex Syndrome Secondary to Herpes Zoster Ophthalmicus: A Case of Irreversible Optic Nerve Damage. Cureus 2023; 15:e46522. [PMID: 37927715 PMCID: PMC10625339 DOI: 10.7759/cureus.46522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/07/2023] Open
Abstract
Herpes zoster ophthalmicus (HZO) arises because of the reactivation of latent varicella-zoster virus (VZV) infection in the trigeminal nerve ganglion and typically presents with ocular manifestations. However, infrequent neurological complications can also be seen. Rarely occurring, orbital apex syndrome presents itself as a severe complication of HZO, characterized by the involvement of multiple cranial nerves and vascular structures within the orbital apex. A 70-year-old male patient being followed for HZO developed orbital apex syndrome after 14 days of treatment, resulting in ophthalmoplegia, vision loss, and significant morbidity. Clinical diagnosis was confirmed by magnetic resonance imaging of the orbit. The treatment involved a combination of systemic steroid and antiviral therapy, resulting in a favorable resolution of ophthalmoplegia within six months. However, optic-neuropathy-induced vision loss was irreparable. Early recognition, antiviral therapy, and multidisciplinary management are crucial in preventing permanent visual impairment and neurological deficits associated with this uncommon complication.
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Takai Y, Yamagami A, Iwasa M, Inoue K, Wakakura M. A Case of Herpes Zoster Ophthalmicus With Multiple Delayed Ocular Complications. Cureus 2023; 15:e37134. [PMID: 37153243 PMCID: PMC10159690 DOI: 10.7759/cureus.37134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 04/07/2023] Open
Abstract
Herpes zoster ophthalmicus (HZO) presents a variety of ocular complications, most of which occur simultaneously as skin lesions. We report a case of HZO with delayed onset of multiple ocular complications. A 72-year-old man developed HZO, blepharitis, iritis, and conjunctivitis in the left eye, which resolved after topical ocular treatment and systemic acyclovir administration. However, six weeks after the first onset of the rash, the patient came to our hospital because of recurrent blepharitis, iritis, scleritis, conjunctivitis, eye pain, ptosis, and blurred vision in the left eye. Best corrected visual acuity (BCVA) in the left eye had decreased to hand motion, and the Goldmann visual field test showed only mild residual peripheral vision on the lateral side. Intraocular pressure showed 25 mmHg in the left eye and inflammation in the anterior chamber with paralytic mydriasis. Orbital magnetic resonance imaging (MRI) showed the contrast effects with the lacrimal gland, superior ophthalmic vein, supraorbital nerve, optic nerve, and around optic nerve sheath. The patient was diagnosed with optic neuritis, optic perineuritis, ptosis, paralytic mydriasis, trigeminal neuralgia, lacrimal gland inflammation, blepharitis, iritis, scleritis, and ocular hypertension after HZO, and three courses of steroid pulse therapy were administered. Thereafter, BCVA improved to 0.3 in the left eye, with improvement in central vision, and MRI lesions and other symptoms also improved. The patient has had no complications or recurrence of HZO. HZO can cause a variety of ocular complications. Since autoimmune mechanisms might be involved, combined immunotherapy should be considered.
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Srimanan W, Panyakorn S. Orbital apex syndrome due to herpes zoster infection in a patient with chronic kidney disease: A case report. Clin Case Rep 2023; 11:e6839. [PMID: 36654694 PMCID: PMC9834609 DOI: 10.1002/ccr3.6839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 01/13/2023] Open
Abstract
We report the case of an 89-year-old man with typical herpes zoster ophthalmicus on the left side of his face with delayed clinical presentation of orbital apex syndrome. After treatment with intravenous antiviral agents and corticosteroids, the patient fully recovered. Clinical suspicion should be concerned in immunocompromised cases.
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Ma Y, Tian Y, Chen X, Agrawal R, Feng Y. Bilateral Pupillary Involvement as a Clinical Presentation of Herpes Zoster Ophthalmicus. Ocul Immunol Inflamm 2023; 31:87-91. [PMID: 34637674 DOI: 10.1080/09273948.2021.1986075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Herpes zoster ophthalmicus (HZO) is traditionally considered as an unilateral disease. However, subclinical involvements in the contralateral eye structures are evidence, giving rise to a broader understanding of varicella-zoster virus (VZV) infection. METHODS We enrolled 20 eyes of 10 patients with HZO and 12 eyes of healthy controls to investigate the bilateral features of HZO patients using a hand-held pupillometer and a Cochet-Bonnet esthesiometer. RESULTS Maximum pupil size before constriction (INT) and minimum diameter when pupil constricts at peak (END) were significantly smaller in patients affected eyes compared with those in controls (p < .05). Interestingly, INT and END were significantly reduced in contralateral eyes of 20 affected patients and also in comparison to control group (p < .001 and p = .034 respectively). CONCLUSION The contralateral eyes may have subclinical involvement in patients with HZO based on significantly abnormal pupillary light reflex (PLR). Pupillometer provides a primary and convenient method to investigate the anatomy and pathology of the PLR.
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Affiliation(s)
- Yan Ma
- Department of Neurology, Peking University Third Hospital, Bejing, China
| | | | - Xia Chen
- Department of Ophthalmology, Daping Hospital, Army Medical University, Chongqing, China
| | - Rupesh Agrawal
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.,Singapore Eye Research Institute, Singapore, Singapore.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Yun Feng
- Department of Ophthalmology, Peking University Third Hospital; Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital, Bejing, China
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Li Y, Tong L, Quek C, Feng Y. The Role of Nervous System and Immune System in Herpes Zoster Ophthalmicus Dissemination and Laterality - Current Views. Ocul Immunol Inflamm 2022; 31:810-818. [PMID: 35412940 DOI: 10.1080/09273948.2022.2058556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Herpes zoster ophthalmicus (HZO) is a sight-threatening condition that is defined as HZ involving the ophthalmic division of the trigeminal nerve. Cases of bilateral HZO in recent literature question the notion of HZO being a strictly unilateral disease. Its pathogenesis is a topic of debate and current literature on VZV dissemination lacks insight into the underlying immunology. This review focuses on novel research in immunology of HZO and aims to formulate hypotheses of spread of lesions through the CNS. METHODS A literature search was conducted on Entrez PubMed using the search terms "bilateral" and "herpes zoster ophthalmicus". Articles on ("Immunology" or "immune cells") and "herpes zoster ophthalmicus" were also searched for. Articles published from January 1942 to April 2020 that were in English language were included. RESULTS Our findings revealed that hypothesised mechanisms of dissemination causing bilateral ocular disease include transmission from nerves to vessel walls, the synergistic action of the immune and nervous systems through the action of substance P and the von Szily reaction. CONCLUSIONS These mechanisms may be investigated using newer models of animal experimentation. It is imperative to define the molecular mechanisms behind VZV transmission to improve methods of identification, treatment, and prevention of HZO.
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Affiliation(s)
- Yue Li
- Department of Ophthalmology, Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital, Beijing, Haidian, China
| | - Louis Tong
- Cornea and External Eye Disease Service, Singapore National Eye Centre, Singapore, Singapore.,Ocular Surface Research Group, Singapore Eye Research Institute, Singapore, Singapore.,Clinical Program, Duke-National University of Singapore Medical School, Singapore, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chrystie Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yun Feng
- Department of Ophthalmology, Beijing Key Laboratory of Restoration of Damaged Ocular Nerve, Peking University Third Hospital, Beijing, Haidian, China
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Pintwala RC, Sawatzky LA, Wong VA, Sheldon CA. Varicella-zoster virus-induced orbital apex syndrome with superior ophthalmic vein occlusion and malignant intraocular pressure rise. Can J Ophthalmol 2021; 57:e129-e130. [PMID: 34752736 DOI: 10.1016/j.jcjo.2021.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 10/19/2022]
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Lim JJ, Ong YM, Wan Zalina MZ, Choo MM. Herpes Zoster Ophthalmicus with Orbital Apex Syndrome—Difference in Outcomes and Literature Review. Ocul Immunol Inflamm 2017. [DOI: 10.1080/09273948.2017.1327604] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jie Jie Lim
- Department of Ophthalmology, Hospital Selayang, Selangor, Malaysia
- Department of Ophthalmology, University of Malaya, Kuala Lumpur, Malaysia
| | - Yu Ming Ong
- Department of Ophthalmology, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - M. Zain Wan Zalina
- Department of Ophthalmology, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - May May Choo
- Department of Ophthalmology, University of Malaya, Kuala Lumpur, Malaysia
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Jensen H, Thomsen ST, Hansen SS, Munksgaard SB, Lindelof M. Superior Orbital Fissure Syndrome and Ophthalmoplegia Caused by Varicella Zoster Virus with No Skin Eruption in a Patient Treated with Tumor Necrosis Alpha Inhibitor. Case Rep Neurol 2015; 7:221-6. [PMID: 26600786 PMCID: PMC4649727 DOI: 10.1159/000441325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Varicella zoster virus lies dormant in the dorsal root ganglia after symptomatic chicken pox infection, usually in childhood. If the virus reactivates in the trigeminal ganglia, it can cause varicella zoster ophthalmicus, which can have severe ocular complications. We report a case of a 73-year-old woman in severe immunosuppression due to treatment with mycophenolate mofetil, glucocorticosteroids and a tumor necrosis factor alpha inhibitor. The reactivation caused superior orbital fissure syndrome, which has only rarely been described in relation to varicella zoster virus reactivation. In our case, the syndrome was seen along with severe encephalitis.
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Hwang SS, Lee SJ. Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.9.1467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sung Soo Hwang
- Department of Ophthalmology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Soo Jung Lee
- Department of Ophthalmology, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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Merino-Iglesias A, Montero JA, Calabuig-Goena M, Giraldo-Agudelo LF. Orbital apex syndrome secondary to herpes zoster virus infection. BMJ Case Rep 2014; 2014:bcr-2013-203200. [PMID: 24614776 DOI: 10.1136/bcr-2013-203200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A male patient with herpes zoster ophthalmicus (HZO) presented with left exophthalmos, external and internal ophthalmoplegia and decreased visual acuity. A CT scan revealed myositis without significant compression of the optic nerve. Intravenous acyclovir and oral steroids were started with improvement of the symptoms and eventual complete recovery.Orbital apex syndrome is a rare complication of HZO. Multiple pathogenic mechanisms are involved, including a direct cytopathic effect of the virus as in the present case. Early diagnosis and therapy may lead to complete recovery of visual function.
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Affiliation(s)
- Alexia Merino-Iglesias
- Department of Ophthalmology, Pio del Rio Hortega University Hospital, Valladolid, Valladolid, Spain
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Yawn BP, Wollan PC, St Sauver JL, Butterfield LC. Herpes zoster eye complications: rates and trends. Mayo Clin Proc 2013; 88:562-70. [PMID: 23664666 PMCID: PMC3788821 DOI: 10.1016/j.mayocp.2013.03.014] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 02/26/2013] [Accepted: 03/07/2013] [Indexed: 11/22/2022]
Abstract
PURPOSE To provide population-based data on the risk, types, and outcomes of eye involvement in herpes zoster (HZ). METHODS A cohort study based on review of the medical records of patients in whom HZ was diagnosed between January 1, 1980, and December 31, 2007, was performed. Herpes zoster was confirmed by the presence of the typical rash and symptoms or by laboratory testing, and eye involvement was confirmed by ophthalmologists' evaluation. Information was collected on all eye diagnoses and on HZ eye-related visits, treatments, procedures, and outcomes. RESULTS Of the 2035 individuals with HZ in any dermatome, 184 (9.0%) had eye involvement. The mean age of the 184 was 62.6 years, and 5 cases occurred in patients younger than 21. Overall, 6.5% (12) were immunosuppressed at the time of the eye complications. The rate of increase in HZ eye involvement was 23% by decade from 1980 to 2007. Common eye complications were keratitis (n=144, 76.2%), uveitis/iritis (n=88, 46.6%), and conjunctivitis (n=67, 35.4%). Recurrent keratitis and recurrent iritis/uveitis occurred in 6.9% (13) and 7.4% (14), respectively. Outcomes included 6 patients (3.3%) with new vision decrements to 20/200 or worse. Two individuals had successful corneal transplants. Another 6 individuals (3.3%) had lid ptosis that affected vision, including 1 elderly woman with permanent unilateral tarsorrhaphy. Severe HZ eye pain was reported to be directly responsible for 1 unsuccessful suicide attempt. Acute retinal necrosis did not develop in any individual. A mean of 10.8 eye visits per patient with HZ and eye involvement was reported to continue for a mean of 308 days. CONCLUSION Eye complications are common and result in considerable health care use and permanent vision decrement in about 6.6% (6) of individuals with HZ eye involvement. Most health care use and long-term adverse outcomes occurred in patients in whom prevention of HZ with the zoster vaccine would be possible.
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Affiliation(s)
- Barbara P Yawn
- Department of Research, Olmsted Medical Center, Rochester, MN 55904, USA.
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