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Year : 1990  |  Volume : 56  |  Issue : 6  |  Page : 454-455

Herpes zoster ophthalmicus with total ophthalmoplegia

Correspondence Address:
S Talwar

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A case of unilateral herpes zoster ophthalmicus (HZO) is reported with ipsilateral involvement of III, IV and VI cranial nerves which led to extra ocular muscles palsy presenting as total ophthalmopegia along with ptosis, cycloplegia and dilated non reactive pupil.

Keywords: Herpes zoster ophthalmicus, Cranial nerve palsy.

How to cite this article:
Talwar S, Srivastava V K. Herpes zoster ophthalmicus with total ophthalmoplegia. Indian J Dermatol Venereol Leprol 1990;56:454-5

How to cite this URL:
Talwar S, Srivastava V K. Herpes zoster ophthalmicus with total ophthalmoplegia. Indian J Dermatol Venereol Leprol [serial online] 1990 [cited 2020 May 31];56:454-5. Available from: http://www.ijdvl.com/text.asp?1990/56/6/454/3602

It is generally believed that following varicella infection the virus traverses along the sensory afferents, gets lodged in sensory ganglion and later; on reactivation, traverses back through the same route to produce clinical lesions.[1] However virus has not been cultured from the sensory ganglion of the asymptomatic individuals, its nucleic acid has been demonstrated indicating presence of the virus.[2] It may occasionaly involve motor neurons leading to paresis/paralysis of the muscles supplied by the affected segment.[3] Among cranial nerves ophthalmic division of triennial nerve is the commonest nerve to be involved. Its involvement has been reported to be 6.52%[4] to 17.47%.[5] Rarely involvement of III, IV and VI cranial nerves has been reported in various combinations in zoster.[5],[7]' However as per authors knowledge there is no reported case of herpetic palsy involving III, IV and VI cranial nerves in Indian literature including largest series of 230 cases of herpes zoster by Chaudhary et al.[4]

  Case Report Top

Seventy, four years old made developed pain along ophthalmic division of left trigeminal nerve. Three days after the onset of pain he developed multiple grouped vesiculobullous lesions on erythematous base along the same segment including side of the nose. Simultaneously he noticed inability to open the left eyelid. Examination of the left eye revealed ptosis, congestion and chemosis of conjunctiva, loss of corneal sensations, dilated and non reactive pupil, loss of all movements of eye ball and cycloplegia (total ophthalmoplegia). However motor functions of the trigeminal nerve were normal. No past history of chickenpox or evidence suggestive of immunosuppression could be elicited. Leucocyte count was 10,000/ - cmm with 70% polymorphs, ESR was 40 mm/ hr. Blood sugar and X-ray skull were within normal limits. Tzanck smear was consistent with the diagnosis of herpes zoster. Diagnosis of ophthalmic zoster with total ophthalmoplegia due to involvement of III, IV and VI cranial nerves was made and patient was given 20 mg equivalent of prednisolone, analgesics, local applications of 1% silver sulphadiazine cream and Chloromycetin eye drops. Skin lesions regressed in 20 days leaving depigmentation, hypoaesthesia and post herpetic neuralgia in the affected segment. Eye lesions except for III, IV and VI nerve palsy regressed fully without any complications in 25 days.

  Comments Top

In inflammation of the trigeminal ganglion, symptoms can be confined to any of its three divisions, but it is the ophthalmic division which is most frequently involved.[8] The ophthalmic division after lying in the lateral wall of the cavernous sinus along with III, IV and VI cranial nerves enters orbit through the superior orbital fissure. HZO may affect any of the ocular motor nerves because of this proximity, particularly the trochlear which shares common sheath with the ophthalmic division.[9] Rucker[10],[11] analysed 2000 cases of ocular motor nerve palsy; herpes zoster was regarded as a rare cause accounting for III nerve palsy alone in 5 cases, IV nerve palsy in 1 case, combined III and IV nerve palsy in 1 case and combined III and VI nerve palsy in 1 case. There was no case of combined III, IV and VI cranial nerve palsy due to HZO. Rush[12] found 1 case out of 119 cases of combined III, IV and VI nerve palsy to be due to HZO. Rarity of the involvement of cranial nerves has also been observed in the study of Burgoon et al[5] where 1 case of extra ocular muscles palsy was reported among 36 patients of HZO. However, the involvement of cranial nerve was not specified. Similarly Juel­Jensen[6] have also reported 3 cases of extra ocular muscles palsy among 56 cases of HZO without specifying the cranial nerves. Recently oral acyclovir has been recommended as an out-patient treatment to prevent serious complications of HZ.[13] Specifically oral acyclovir given as late as 7 days after onset of cutaneous lesions has been shown to confer a beneficial prophylactic effect with respect to ocular complications of HZO.[14]

  References Top

1.Hope-Simpson RE : The nature of herpes zoster a long term study and a new hypothesis, Proc Roy Soc Med, 1965; 58 : 9-20.  Back to cited text no. 1    
2.Adams DR and Victor M : Principles of Neurology, Fourth ed, McGraw-Hill Information Service Company, New York, 1989; p 596.  Back to cited text no. 2    
3.Denny - Brown D, Adams RD and Fitzgerald PJ Pathologic features of herpes zoster : a note on 'geniculate herpes, Arch Neurol Psychiatr, 1944; 51 : 216-231.  Back to cited text no. 3    
4.Chaudhary SD, Dashore A and Pahwa US : A clinicoepidemiologic profile of herpes zoster in North India, Ind J Dermatol Venereol Leprol, 1987; 53 213-216.  Back to cited text no. 4    
5.Burgoon CF, Burgoon JS and Balridge GD : The natural history of herpes zoster, J Amer Med Assoc, 1957; 164 : 265-269.  Back to cited text no. 5    
6.Juel-Jensen BE : Vericellazoster virus infections chickenpox and zoster, in : Oxford Text Book of Medicine, Second ed, Editors, Weatherall DJ, Ledingham JGG, Warrell DA : Oxford University Press, Oxford, 1983; p 570.  Back to cited text no. 6    
7.Blank H, Eaglestein WH and Gold-faden GL Zoster, a recrudescence of V-Z virus infection, Post Grad Med J, 1970, 46 : 653-658.  Back to cited text no. 7    
8.Brain L and Walton JN : Brains Diseases of the Nervous system, Seventh ed, Oxford University Press, London, 1969; p 159.  Back to cited text no. 8    
9.Reference 2, p 216.  Back to cited text no. 9    
10.Rucker CW : Paralysis of third, fourth and sixth cranial nerves, Amer J Ophthalmol, 1958; 46 : 787­794.  Back to cited text no. 10    
11.Rucker CW : The causes of paralysis of third, fourth and sixth cranial nerves, Amer J Ophthalmol, 1966; 61 : 1293-1298.  Back to cited text no. 11    
12.Rush AJ and Younge RB : Paraysis of cranial nerves III, IV and VI, Arch Ophthalmol, 1981; 99 76-79.  Back to cited text no. 12    
13.Huff JC, Bean B, Balfour HH Jr et al : Therapy of herpes zoster with oral acyclovir, Amer J Med, 1988; 85 (Suppl 2A) : 84-89.  Back to cited text no. 13    
14.Cobo M : Reduction of the ocular complications of herpes zoster ophthalmicus by oral acyclovir, Amer J Med, 1988; 85 (Suppl 2A) : 90-93  Back to cited text no. 14    


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