Case Series: Herpes Zoster Ophthalmicus with Acute Orbital Inflammation.

SIGNIFICANCE: Herpes zoster ophthalmicus (HZO) has variable initial manifestations, and acute orbital inflammation may be the first sign without apparent zoster rash. This case series is significant for presenting diverse clinical features and treatment options of HZO with acute orbital inflammation. PURPOSE: To report a case series of patients diagnosed as HZO with acute orbital inflammation including two cases with unique presentations. CASE REPORTS: Medical records of four patients of HZO with acute orbital inflammation were reviewed. Two men and two women with a median age of 57 years (range, 32 to 69 years) were diagnosed as having HZO with acute orbital inflammation. Initial presentations included two cases of zoster rash and two cases of orbital pain preceding vesicles. Clinical orbital findings included proptosis, ptosis, ophthalmoplegia, and decreased visual acuity. Orbital magnetic resonance image showed enlarged extraocular muscle with enhancement and optic nerve sheath enhancement in all four patients, and unilateral dacryoadenitis in one patient. All four patients were administered with systemic steroid, three patients received intravenous acyclovir, and one patient received oral acyclovir. Orbital signs improved in all patients over several months. CONCLUSIONS: Herpes zoster ophthalmicus may initially present with orbital inflammatory signs, such as acute orbital myositis, perioptic neuritis, or dacryoadenitis, without zoster rash. Physicians should be aware of acute orbital inflammation as a presenting sign of HZO.

New Onset of Unilateral Orbital Myositis following Mild COVID-19 Infection.

Purpose: The authors present a case of unilateral orbital myositis of new onset following COVID-19 without a severe course.Methods: The patient had been received topical treatment with a preliminary diagnosis of conjunctivitis but no recovery had been noticed. The history revealed that the ocular signs had started 1 week after the COVID-19.Results: The examination revealed sectoral hyperemia of the temporal region in the bulbar conjunctiva together with marked limitation of right inward gaze. MRI of the orbits demonstrated diffuse fusiform enhancing enlargement of the right lateral rectus and superior rectus. The results of the laboratory tests and examination findings were normal. Systemic corticosteroids were started for the orbital myositis.Conclusions: Although conjunctivitis is the more common ocular disease following COVID-19, the possibility of orbital myositis should be considered in cases with resistance to topical treatment and/or gaze limitation. The possible role of orbital myositis as a trigger for COVID-19 could be explained with an immune-mediated mechanism.

External ophthalmoplegia with orbital myositis in an adult patient after chickenpox infection.

Herpes zoster and chickenpox are caused by a single virus, varicella-zoster virus. Herpes zoster ophthalmicus-associated ophthalmoplegia is well documented. Very rarely, herpes zoster and chickenpox cause external ophthalmoplegia. A 48-year-old man was diagnosed with chickenpox and treated with intravenous acyclovir. He suddenly reported diplopia and restricted left eye movement. MRI of the orbit revealed thickening and abnormal contrast enhancement of the preseptal space and lateral rectus muscle of the left eye. In this case, external ophthalmoplegia occurred following chickenpox with radiological evidence of orbital myositis. To the best of our knowledge, this is the first case report of external ophthalmoplegia of radiologically confirmed orbital myositis after chickenpox infection.

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

Viral infection is a rare cause of painful ophthalmoplegia. We report on a 67-year-old patient who developed painful double vision after a vesicular skin rash on the left forehead. MRI disclosed simultaneous inflammatory lesions in all extraocular muscles, the second and third cranial nerve, as well as pathological signal intensity along the spinal trigeminal tract and nucleus within the medulla oblongata and the pons. Cerebrospinal fluid and serum tests for varicella zoster were positive. The patient was treated effectively with intravenous acyclovir and methylprednisolone. Simultaneous lesions in various neighbouring neural structures may be characteristic for the highly neurotropic behaviour of the herpesviridae and should be considered as a cause of painful ophthalmoplegia that can be depicted by appropriate imaging.