title: Orbital apex syndrome: an unusual complication of herpes zoster ophthalmicus.
abstract: BACKGROUND
  Herpes zoster ophthalmicus is defined as herpes zoster involvement of the ophthalmic division of the trigeminal nerve. Ocular involvement occurs in 20-70% of patients with herpes zoster ophthalmicus and may include blepharitis, keratoconjunctivitis, iritis, scleritis, and acute retinal necrosis. Orbital apex syndrome is a rare but severe ocular complication of herpes zoster ophthalmicus. We present here the first reported case of herpes zoster ophthalmicus complicated by orbital apex syndrome in a patient from Taiwan.
  
  
  METHODS
  A 78-year-old man initially presented with patchy erythema and herpetiform vesicles on his left forehead and upper eyelid. He subsequently developed left-sided ocular complications including reduced visual acuity, anisocoria, ptosis, and complete ophthalmoplegia. Orbital magnetic resonance imaging (MRI) was performed on day 6 of admission to search for signs of the common causes of orbital apex syndrome such as hemorrhage, neoplasm, and cavernous sinus thrombosis. The MRI showed only orbital myositis and enhancement of the retro-orbital optic nerve sheath. The patient was diagnosed with herpes zoster ophthalmicus complicated by orbital apex syndrome. Although the ocular complications partially resolved after systemic antiviral therapy for 15 days and steroid therapy tapered over 12 weeks, there was residual limitation of abduction and paralysis of the left upper eyelid at follow-up at 180 days after the onset of symptoms. The orbital MRI findings at 180 days showed no significant changes compared with the MRI findings on day 6 of admission.
  
  
  CONCLUSIONS
  Primary care physicians should be aware of this rare but potentially sight-threatening complication of herpes zoster ophthalmicus. The appropriate therapy for orbital apex syndrome due to herpes zoster ophthalmicus and the potential outcomes of this condition require further investigation.
authors: Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. Leecy8801131@gmail.com.
authors: Chun-Yuan
authors: CY
authors: Lee
authors: Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. hctsai1011@yahoo.com.tw.|Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. hctsai1011@yahoo.com.tw.
authors: Hung-Chin
authors: HC
authors: Tsai
authors: Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. 9811anita@gmail.com.|Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. 9811anita@gmail.com.
authors: Susan Shin-Jung
authors: SS
authors: Lee
authors: Division of Infectious Diseases, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. u9371003@gmail.com.|Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan. u9371003@gmail.com.|Graduate Institute of Science Education and Environmental Education, National Kaohsiung Normal University, Kaohsiung, Taiwan. u9371003@gmail.com.
authors: Yao-Shen
authors: YS
authors: Chen
mesh_terms: D000368:Aged; D015875:Anisocoria / Q000209:etiology*; D006563:Herpes Zoster Ophthalmicus / Q000150:complications* / Q000175:diagnosis; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D009886:Ophthalmoplegia / Q000209:etiology*; D013577:Syndrome
references: Ophthalmology. 2008 Feb;115(2 Suppl):S3-12
references: 18243930
references: Indian Dermatol Online J. 2013 Oct;4(4):369
references: 24350029
references: Am J Ophthalmol. 1967 Jun;63(6):1796-8
references: 5298081
references: Indian J Ophthalmol. 2010 Nov-Dec;58(6):527-30
references: 20952840
references: Br J Ophthalmol. 1977 Nov;61(11):677-82
references: 338027
references: Clin Ophthalmol. 2011;5:1603-8
references: 22140305
references: Am J Ophthalmol. 1968 Apr;65(4):533-41
references: 5300433
references: J Neuroophthalmol. 1997 Dec;17(4):262-5
references: 9427180
references: Br J Ophthalmol. 1987 May;71(5):353-8
references: 3495293
references: Arch Ophthalmol. 1983 Jan;101(1):42-5
references: 6600391
references: Clin Infect Dis. 2007 Jan 1;44 Suppl 1:S1-26
references: 17143845
references: Case Rep Ophthalmol Med. 2012;2012:854503
references: 22830066
references: J Neuroophthalmol. 2009 Dec;29(4):325-37
references: 19952908
references: Open Ophthalmol J. 2008 Jun 03;2:109-11
references: 19517035
references: Orbit. 2008;27(4):325-7
references: 18716975
references: Korean J Ophthalmol. 2005 Dec;19(4):302-4
references: 16491822