• Users Online: 1131
  • Print this page
  • Email this page

Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 45

Superior orbital fissure syndrome secondary to ophthalmic herpes zoster: Case Report

Department of Ophthalmology, General Regional Hospital, Merida, Yucatan, Mexico

Date of Submission23-Jul-2022
Date of Decision14-Aug-2022
Date of Acceptance15-Aug-2022
Date of Web Publication22-Sep-2022

Correspondence Address:
Joel Isai Quetzal Herrera
Avenue Miguel Hidalgo 216, Garcia Gineres, 97070 Merida, Yucatan
Katia Marquez Gonzalez
Avenue Miguel Hidalgo 216, García Ginerés, 97070 Mérida, Yucatan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/pajo.pajo_41_22

Rights and Permissions

Objective: The objective of this study is to report a case of superior orbital fissure syndrome (SOFS), secondary to ocular herpes zoster, with a favorable evolution.
Materials and Methods: Herpes zoster ophthalmicus (HZO) usually presents with ocular manifestations, being infrequent with the ophthalmoplegia. SOFS secondary to HZO is rare. We present the case of a 72-year-old man with dermatome involvement of the first left trigeminal branch, secondary to herpes zoster infection, who also developed herpetic keratitis in the left eye. After 8 days of antiviral treatment, he developed total left eye ophthalmoplegia that required steroid treatment. The evolution of the ophthalmoplegia was favorable with resolution at 3 months of follow-up.
Conclusions: It is essential to make known one of the complications of HZO infection, although not as frequent, just as important, is to recognize this pathology when it occurs for prompt management and recovery.

Keywords: Herpes zoster, neurological manifestations, ophthalmoplegia, orbital apex syndrome, orbital fissure syndrome

How to cite this article:
Gonzalez KM, Quetzal Herrera JI. Superior orbital fissure syndrome secondary to ophthalmic herpes zoster: Case Report. Pan Am J Ophthalmol 2022;4:45

How to cite this URL:
Gonzalez KM, Quetzal Herrera JI. Superior orbital fissure syndrome secondary to ophthalmic herpes zoster: Case Report. Pan Am J Ophthalmol [serial online] 2022 [cited 2023 May 28];4:45. Available from: https://www.thepajo.org/text.asp?2022/4/1/45/356712

  Introduction Top

Varicella-zoster virus (VZV) is a DNA virus that is part of the herpesviridae family, it is neurotrophic and its main reservoir is found in humans. Herpes zoster ophthalmicus (HZO) is defined as herpes zoster virus (HZV) involvement of the ophthalmic division of the trigeminal nerve (CNV1).[1] In the literature, HZO represents 7% of all cases of herpes zoster,[2] and can include blepharitis, conjunctivitis, keratitis, uveitis, and retinal manifestations.[3]

Cases of superior orbital fissure syndrome (SOFS) due to HZO have been reported in the literature; however, they are rare.[4],[5] We present the case of a 72-year-old patient with SOFS secondary to HZO.

  Case Report Top

A 72-year-old male patient presented to the ophthalmology department reporting a skin rash, increased volume, and redness in the upper left eyelid region. In addition, he complained of pain in the upper and lower eyelids of the left eye. In laboratory studies performed at the time of consultation, diagnosis of type 2 diabetes mellitus was made. On examination, vesicular lesions were observed in the frontal region, orbit, tip, and dorsum of the nose (Hutchinson's sign) compatible with HZO.

His best visual acuity in the right eye was 20/30, and in the left eye, it was 20/50. The intraocular pressure was 22 mmHg in both eyes. The primary gaze position was in orthoposition, without limitation in eye movement.

In addition, he presented with blepharedema and Eyelid erythema. Biomicroscopy revealed conjunctiva with mixed hyperemia, chemosis, cornea with superficial punctate keratopathy, and crystalline with slight opacity. Fundoscopy was normal. The patient was diagnosed with HZO, and treatment was started with acyclovir 800 mg every 4 h, acyclovir ointment every 4 h for 10 days, and ciprofloxacin (ophthalmic solution).

On the 18th day of treatment, the patient reported a left hemicranial headache, with severe intensity and inability to open the left eyelid. Ophthalmological examination revealed severe left ptosis and total limitation of all ocular movements of the left eye; to the biomicroscopy, pseudodendrites, and stromal edema [Figure 1]. In addition, corneal hypoesthesia was found. Due to the increase in volume and the total paralysis of the left eye, an orbital tomography was requested, without evidence of tumor lesions [Figure 2].
Figure 1: (a) Clinical photo showing skin lesions on the left side of the face, as well as left ptosis. (b) Biomicroscopy of the left eye, showing conjunctival hyperemia, cornea with stromal edema

Click here to view
Figure 2: Simple tomography of the skull and orbits, without evidence of tumor lesions

Click here to view

After 11 days of antiviral treatment, limitation of eye movements was added [Figure 3]. It was decided to start treatment with prednisone 50 mg every 24 h, pregabalin 75 mg every 24 h, and timolol-dorzolamide every 12 h. Seven days after steroid initiation, left eye exotropia and a slight improvement in eye movements were evident [Figure 4].
Figure 3: Strabogram, in which limitation of all the ductions of the left eye is observed

Click here to view
Figure 4: Strabogram, on the 7th day of steroid treatment

Click here to view

Three months after the first symptoms and signs of HZO, the patient presented improvement in both visual acuities, with 20/25 vision in both eyes, and eye movements, showing no limitations to versions or ductions [Figure 5].
Figure 5: Strabogram at 3 months of follow-up

Click here to view

  Discussion Top

In people with a prior history of VZV infection, the virus remains latent within a dorsal root ganglion. The virus remains inactive in immunocompetent patients; however, the virus can be reactivated in immunocompromised. Involvement of the ophthalmic nerve (V1) gives rise to HZO after being latent within the Gasserian ganglion. HZV infection can affect any of the three branches of CNV.[1]

The lifetime risk of developing herpes zoster is estimated at 25% and for those over 85 years of age, the risk increases to 50%.[6] Among patients diagnosed with herpes zoster, some epidemiological studies estimate that around 8% to 20% are complicated by HZO.[7] Of HZO cases, 20% to 79% have orbital involvement.[8] Paralysis of the extraocular muscles in patients with HZO occurs in 3.5%–10.1%.[9] Tran et al. describe recurrence rates at 1, 3, and 5 years for recurrent eye disease or rash of 8%, 17%, and 25%, respectively.[10]

Manifestations of HZO can be classified by anatomical area:

  • Periocular region: Unilateral radicular pain and vesicular rash[11],[12]
  • Conjunctiva: Follicular or papillary conjunctivitis[13]
  • Anterior segment: Episcleritis, scleritis, punctate epithelial keratitis, “pseudodendritic” keratitis, neurotrophic keratopathy, and among other[14]
  • Uvea: Iritis, iris atrophy, iridocyclitis, and panuveitis[15]
  • Vitreous and retina: Exudative or rhegmatogenous retinal detachment, acute retinal necrosis, progressive external retinal necrosis, and progressive outer retinal necrosis[16]
  • Neuro-ophthalmological: Optic neuritis and ophthalmoplegia.[17],[18]

Ophthalmoplegia is one of the secondary neurological manifestations of HZO reported in the literature, whose main manifestation is paralysis of the III CN. Similarly, there are complications that involve more than one cranial nerve such as SOFS, which consists of dysfunction of the III, IV, and VI CN and the ophthalmic division of the nerve trigeminal nerve (V1).[4] Moreover, it differs from orbital apex syndrome (OAS) in that the latter, in addition to having involvement of the previously mentioned nerves, presents affection of the optic nerve (II CN).[19] Therefore, clinically, SOFS can be distinguished from OAS by preserving visual acuity and the pupillary reflex; signs that are compromised in affections of the orbital apex.

The median time to onset of HZV ocular involvement has been reported to be 1.82 weeks after the onset of skin lesions in dermatome V1.[19]

The pathological mechanisms of ophthalmoplegia in HZO cases are not clear. Here are some of the hypotheses that have been raised:

  • Perivascular and perineural inflammation: Histopathologic studies have shown inflammation of the vasculature and neural tissue in various ocular tissues[20],[21],[22]
  • Cytopathic damage to the virus to neural tissue and direct spread of HZV[23]
  • Cranial nerve compression: Caused by edema of the orbital soft tissue[24],[25],[26]
  • Microinfarct: Garg et al., proposed that there may be microinfarct of the cranial nerves.[27]

The available literature on HZO with SOFS reports clinical improvement with the use of steroids and systemic antiviral medications.[5] Recovery time for HZO-related ophthalmoplegia was reported to be 4.4 months on average, with a range of 2 weeks to 1.5 years. Complete recovery rates for ophthalmoplegia and optic neuropathy have been reported as 76.5% and 75%, respectively.[28]

The clinical presentation of our patient with a previous diagnosis of HZO, with subsequent limitation of all eye movements (paralysis of the III, IV, and VI cranial nerves) of the left eye, as well as corneal hypoesthesia, an intact pupillary reflex (absence of optic nerve involvement), was consistent with SOFS. The patient was treated with systemic steroids, presenting complete improvement of the ophthalmoplegia.

Few cases of total ophthalmoplegia due to HZO have been reported; and of these, few are the case reports of SOFS secondary to HZO in the current literature.

  Conclusions Top

Although SOFS secondary to HZV infection is rare, ophthalmologists should be aware that complete ophthalmoplegia can follow cutaneous or ophthalmic herpes zoster infection, so its timely diagnosis and treatment are essential.

Declaration of patient consent

The authors certify that they have obtained patient consent. The patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Minor M, Payne E. Herpes zoster ophthalmicus. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2022. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557779/. [Last updated on 2021 Aug 11].  Back to cited text no. 1
Kim HT, Moon SY, Lee KH. Acute orbital myositis before herpes zoster ophthalmicus. Korean J Anesthesiol 2012;62:295-6.  Back to cited text no. 2
Yawn BP, Wollan PC, St Sauver JL, Butterfield LC. Herpes zoster eye complications: Rates and trends. Mayo Clin Proc 2013;88:562-70.  Back to cited text no. 3
Jensen H, Thomsen ST, Hansen SS, Munksgaard SB, Lindelof M. Superior orbital fissure syndrome and ophthalmoplegia caused by varicella zoster virus with no skin eruption in a patient treated with tumor necrosis alpha inhibitor. Case Rep Neurol 2015;7:221-6.  Back to cited text no. 4
Lavaju P, Badhu BP, Shah S. Herpes zoster ophthalmicus presenting as orbital abscess along with superior orbital fissure syndrome: A case report. Indian J Ophthalmol 2015;63:733-5.  Back to cited text no. 5
[PUBMED]  [Full text]  
Johnson RW. Herpes zoster and postherpetic neuralgia. Expert Rev Vaccines 2010;9:21-6.  Back to cited text no. 6
Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology 2008;115:S3-12.  Back to cited text no. 7
McCrary ML, Severson J, Tyring SK. Varicella zoster virus. J Am Acad Dermatol 1999;41:1-14.  Back to cited text no. 8
Arda H, Mirza E, Gumus K, Oner A, Karakucuk S, Sırakaya E. Orbital apex syndrome in herpes zoster ophthalmicus. Case Rep Ophthalmol Med 2012;2012:854503.  Back to cited text no. 9
Tran K, Falcone M, Choi D, Goldhardt R, Karp C, Davis J, et al. Epidemiology of herpezoster ophthalmicus. Ophthalmology 2016;123:1459-7.  Back to cited text no. 10
BenEzra D, Ohno S, Secchi AG, Alio JL. Anterior Segment Intraocular. Inflammation Guidelines. London, United Kingdom; Taylor and Francis Group; 2000.  Back to cited text no. 11
Gnann JW Jr. Vaccination to prevent herpes zoster in older adults. J Pain 2008;9:S31-6.  Back to cited text no. 12
Kalogeropoulos CD, Bassukas ID, Moschos MM, Tabbara KF. Eye and periocular skin involvement in herpes zoster infection. Med Hypothesis Discov Innov Ophthalmol 2015;4:142-56.  Back to cited text no. 13
Loh SL, Ong WZ. Herpes zoster ophthalmicus with ophthalmoplegia: A case report and review of literature. Thai J Ophthalmol 2564;35:30-7.  Back to cited text no. 14
Groen-Hakan F, Babu K, Tugal-Tutkun I, Pathanapithoon K, de Boer JH, Smith JR. Challenges of diagnosing viral anterior uveitis. Ocul Immunol Inflamm 2017;25:710-20.  Back to cited text no. 15
Wensing B, de Groot-Mijnes JD, Rothova A. Necrotizing and nonnecrotizing variants of herpetic uveitis with posterior segment involvement. Arch Ophthalmol 2011;129:403-8.  Back to cited text no. 16
Smith EF, Santamarina L, Wolintz AH. Herpes zoster ophthalmicus as a cause of Horner syndrome. J Clin Neuroophthalmol 1993;13:250-3.  Back to cited text no. 17
Wang AG, Liu JH, Hsu WM, Lee AF, Yen MY. Optic neuritis in herpes zoster ophthalmicus. Jpn J Ophthalmol 2000;44:550-4.  Back to cited text no. 18
Lee CY, Tsai HC, Lee SS, Chen YS. Orbital apex syndrome: An unusual complication of herpes zoster ophthalmicus. BMC Infect Dis 2015;15:33.  Back to cited text no. 19
Lexa FJ, Galetta SL, Yousem DM, Farber M, Oberholtzer JC, Atlas SW. Herpes zoster ophthalmicus with orbital pseudotumor syndrome complicated by optic nerve infarction and cerebral granulomatous angiitis: MR-pathologic correlation. AJNR Am J Neuroradiol 1993;14:185-90.  Back to cited text no. 20
Edgerton AE. Herpes zoster ophthalmicus: Report of cases and review of literature. Arch Ophthalmol 1945;34:40-62.  Back to cited text no. 21
Naumann G, Gass JD, Font RL. Histopathology of herpes zoster ophthalmicus. Am J Ophthalmol 1968;65:533-41.  Back to cited text no. 22
Im M, Kim BJ, Seo YJ, Park JK, Lee JH. Complete ophthalmoplegia after herpes zoster. Clin Exp Dermatol 2007;32:162-4.  Back to cited text no. 23
Pavan-Langston D. Herpes zoster ophthalmicus. Neurology 1995;45:S50-1.  Back to cited text no. 24
Chang-Godinich A, Lee AG, Brazis PW, Liesegang TJ, Jones DB. Complete ophthalmoplegia after zoster ophthalmicus. J Neuroophthalmol 1997;17:262-5.  Back to cited text no. 25
Krasnianski M, Sievert M, Bau V, Zierz S. External ophthalmoplegia due to ocular myositis in a patient with ophthalmic herpes zoster. Neuromuscul Disord 2004;14:438-41.  Back to cited text no. 26
Garg RK, Kar AM, Jain AK. Herpes zoster ophthalmicus with complete external ophthalmoplegia. Assoc Phys India 1992;40:486-97.  Back to cited text no. 27
Kocaoğlu G, Utine CA, Yaman A, Men S. Orbital apex syndrome secondary to herpes zoster ophthalmicus. Turk J Ophthalmol 2018;48:42-6.  Back to cited text no. 28


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Case Report
Article Figures

 Article Access Statistics
    PDF Downloaded87    
    Comments [Add]    

Recommend this journal