Orbital Apex Syndrome Secondary to Herpes Zoster Ophthalmicus

A 49-year-old woman who complained of lacrimation, foreign body sensation, and eyelid oedema presented to our outpatient clinic. External examination identified erythematous rash with vesicles on the left eyelid, dorsum of the nose, and forehead of the patient. She was diagnosed to have herpes zoster ophthalmicus (HZO), and was started on oral brivudine and topical acyclovir. On the third day of the treatment, visual acuity of left eye was reduced; left blepharoptosis and total ophthalmoplegia had developed. Orbital magnetic resonance imaging (MRI) showed enlargement of the extraocular muscles, and perineural enhancement of the optic nerve on that side. Oral brivudine was replaced with intravenous acyclovir, and oral corticosteroid was initiated. Complete resolution of proptosis and restriction of eye movements were achieved, and significant improvement of visual acuity was observed within a week. Orbital apex syndrome, a severe and rare complication of herpes zoster infection, can develop despite antiviral treatment. Rapid institution of appropriate therapy may provide complete recovery.