Orbital Apex Syndrome Caused by Herpes Zoster in an Immunocompetent Patient: A Case Report

Orbital apex syndrome (OPS) is determined by ophthalmoplegia, vision loss, and involvement of cranial nerves III, IV, VI, and the first branch of the trigeminal nerve. The disease is commonly caused by invasive fungal infections such as mucormycosis and aspergillosis in immunocompromised or immunocompetent patients. Rarely, herpes zoster virus may cause OPS. This report presents the case of a 48 year-old man with right-sided headache, tearing, and conjunctival hyperemia. The patient also gradually developed vision loss, proptosis, ptosis, and right ocular motility disorder within 2-3 days. At this time, there were no skin lesions. Physical examination showed that the visual acuity of the patient was limited to light perception. Also, it revealed decreased visual field of the right eye and fixed eye. In slit lamp examination diffused corneal opacity was seen and brief ocular hypertension was detected in tonometry. After four days, erythema and periorbital vesicular rash occurred around the right eyelid and forehead. Computed tomography scan (CT scan) of the orbits showed severe inflammation in the right intra orbital structures, including the lacrimal glands and extraocular muscles. Early diagnosis of the orbital apex syndrome due to the herpes zoster virus was made and treatment with intravenous acyclovir and corticosteroid and parenteral antibiotics was initiated. The visual acuity improved and uveitis recovered in 20 days. Treatment with oral acyclovir and prednisolone was continued. After four months, ocular movement was normal in all directions and ptosis recovered. Combination therapy with systemic corticosteroid and acyclovir in our immunocompetent patient had a good prognosis.