title: Concurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady.
abstract: BACKGROUND
  Hyphema and orbital apex syndrome occurring concurrently in a patient with herpes zoster ophthalmicus have not been reported previously. We present a case with these unique findings and discuss the pathogenesis of these conditions and their management.
  
  
  METHODS
  A 59-year-old Malay lady with underlying diabetes mellitus presented with manifestations of zoster ophthalmicus in the left eye. Two weeks later, she developed total hyphema, and complete ophthalmoplegia suggestive of orbital apex syndrome. She was treated with combination of intravenous acyclovir and oral corticosteroids, and regained full recovery of ocular motility. Total hyphema persisted, and she required surgical intervention.
  
  
  CONCLUSIONS
  Hyphema is postulated to occur due to an immune vasculitis affecting the iris vessels. Orbital apex syndrome is probably due to an occlusive vasculitis affecting the vasculature of the extraocular muscles and optic nerve, resulting from a direct invasion by varicella zoster virus or infiltration of perivascular inflammatory cells. Magnetic Resonance Imaging of the brain is essential to exclude possibility of local causes at the orbital apex area.
  
  
  CONCLUSIONS
  Herpes zoster ophthalmicus is an uncommon ocular presentation. Managing two concurrent complications; persistent total hyphema and orbital apex syndrome is a challenging clinical situation. Early diagnosis and prompt treatment are essential to prevent potential blinding situation.
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Khairuddin
authors.initials: K
authors.lastname: Othman
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Li Min
authors.initials: LM
authors.lastname: Evelyn-Tai
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Mohd Noor
authors.initials: MN
authors.lastname: Raja-Azmi
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Muhammed
authors.initials: M
authors.lastname: Julieana
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Ahmad Tajudin
authors.initials: AT
authors.lastname: Liza-Sharmini
authors.affiliation: Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: John
authors.initials: J
authors.lastname: Tharakan
authors.affiliation: Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Alwi Muhd
authors.initials: AM
authors.lastname: Besari
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
authors.forename: Embong
authors.initials: E
authors.lastname: Zunaina
authors.affiliation: Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. Electronic address: shatriah@usm.my.
authors.forename: Ismail
authors.initials: I
authors.lastname: Shatriah
keywords: Herpes zoster ophthalmicus; Orbital apex syndrome; Persistent hyphema