J Korean Ophthalmol Soc.  2015 Sep;56(9):1467-1472. 10.3341/jkos.2015.56.9.1467.

Complete Oculomotor Nerve Palsy Complicated by Inflammation of the Cavernous Sinus in Herpes Zoster Ophthalmicus

• Hwang SS
• Lee SJ

• KMID: 2214566
• DOI: http://doi.org/10.3341/jkos.2015.56.9.1467

Abstract

PURPOSE
To report a case of complete oculomotor nerve palsy with pupil involvement complicated by inflammation of the cavernous sinus. Complete resolution was obtained after 12 days of antiviral and steroid treatments.
CASE SUMMARY
A 60-year-old male presented with edema and vesicles of the right upper eyelid. The patient had myalgia, cough, fever and headache 1 week earlier and was treated with conservative therapy. The patient received an antiviral agent (famciclovir 250 mg) twice a day and steroid agent (methylprednisolon 4 mg) once a day at the dermatology department for 1 week. The eyelid edema and vesicles improved. However, ptosis, ocular movement limitation, mydriasis of the right eye and diplopia occurred. Brain magnetic resonance imaging revealed hyperintensity in the right cavernous sinus with enhancement, implicating inflammation. The patient was diagnosed with right complete oculomotor nerve palsy with pupil involvement. An antiviral agent (famciclovir 250 mg) three times a day and a steroid agent (prednisolone 40 mg) once a day were prescribed. From the next day, ptosis and ocular movement limitation improved and 12 days later, completely resolved.
CONCLUSIONS
Ocular movement limitation and mydriasis can be accompanied by herpes zoster ophthalmicus without uveitis and cerebral aneurysm. Administering active antiviral and steroid treatment to obtain rapid resolution is important.

Keyword

Cavernous sinus; Herpes zoster ophthalmicus; Oculomotor nerve palsy; Pupil; Steroid

MeSH Terms

Brain
Cavernous Sinus*
Cough
Dermatology
Diplopia
Edema
Eyelids
Fever
Headache
Herpes Zoster Ophthalmicus*
Herpes Zoster*
Humans
Inflammation*
Intracranial Aneurysm
Magnetic Resonance Imaging
Male
Middle Aged
Myalgia
Mydriasis
Oculomotor Nerve Diseases*
Oculomotor Nerve*
Pupil
Uveitis

Figure

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  Figure 1. Patient's photograph before retreatment. The patient had mild swelling and ptosis of the right upper eyelid. There was no exophthalmos.

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  Figure 2. Nine cardinal gaze photos before retreatment. Nine cardinal gaze photographs shows limitation of adduction, elevation and depression of the right eye.

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  Figure 3. Pupil size before retreatment. The pupils were anisocoric and unequally reactive to light. The reaction of the pupil of the right eye was sluggish, whereas the pupil of the left eye was brisk. In bright light, the pupils were 6 mm (A) in the right eye and 2 mm (B) in the left eye.

• 

  Figure 4. Brain magnetic resonance image. (A) FLAIR image and (B) contrast enhanced T1 fast field echo image reveals hyper-intensity in the superolateral portion of the right cavernous sinus (arrow) and encagement of the third nerve is observed (arrowheads). FLAIR = fluid attenuated inversion recovery.

• 

  Figure 5. Nine cardinal gaze photos after retreatment. Twelve days after retreatment, nine cardinal gaze photographs shows no ocu-lar movement limitation of the right eye. The ptosis of the right eye resolved completely.

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  Figure 6. Pupil size after retreatment. Twelve days after retreatment, pupil size of (A) right eye and (B) the left eye was equal and 2 mm.

Reference

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