Orbital Apex Syndrome secondary to Herpes Zoster Ophthalmicus (HZO) This 81 yo male was referred to our for an evaluation for possible orbital cellulitis. The patient reported this all began when he developed shingles around his left eye six weeks prior. He was treated by his PCP with valacyclovir initially. He reported improvement in the rash but his left eye developed a complete ptosis, severe ophthalmoplegia, a non-reactive pupil, and HM vision. Additionally, slit lamp exam revealed a uveitis. The patient was started on 1g valacyclovir TID and started on prednisolone acetate to help with ocular inflammation. Due to the additional neuro findings, the patient was sent to the emergency room for imaging to rule out other potential causes. The MRI findings included abnormal enhancement of the optic nerve with crowding at the orbital apex and an increase in the size and signal of the EOMs consistent with Orbital Apex Syndrome secondary to Herpes Zoster Ophthalmicus (HZO). The patient underwent IV acyclovir 10mg/kg/8hr and also began oral prednisone (20 mg TID). Orbital Apex Syndrome is a rare complication of HZO which involves inflammation of the nerves coming through the superior orbital fissure and optic canal. The nerves at the apex include the optic nerve, oculomotor nerve, trochlear nerve, abducens nerve, and ophthalmic branch of the trigeminal nerve. This condition can be sight threatening if the patient doesn’t receive proper treatment in a timely manner. Neurological defects from HZO usually occur within the first two weeks of the initial forehead lesions. Although there is no mainstay treatment for the condition, case studies have shown that patients dramatically improve with IV/oral antivirals along with oral steroids (some cases have also shown a good response to IV steroids as well). Bennett & Bloom Eye Center @anterior_seg_rocks #Orbital #Apex #Syndrome #Herpes #Zoster #Ophthalmicus #HZO #clinical #video #ophthalmology #physicalexam #neurology
