A Series Of Unfortunate Events: A Case Of Viral Meningitis Secondary To Orbital Apex Syndrome Secondary To Herpes Zoster Ophthalmicus With Herpes Zoster Keratouveitis

Orbital apex syndrome is a rare neuro-ophthalmic manifestation of herpes zoster virus infection. Two of its consequences if left untreated are viral meningitis and cerebrovascular disease. Early diagnosis and treatment of herpes zoster ophthalmicus is crucial so as to avoid more life-threatening systemic and neurologic complications.

The setting of this case is at the East Avenue Medical Center- DOH Eye Center, a tertiary government hospital in Diliman, Quezon City, Metro Manila, Philippines.

This is a case of a 74 year old female who consulted for vesicular rashes on the right periocular area. History revealed that two weeks prior to consult, patient noted appearance of vesicular, painful rashes on her forehead, right periorbital area, extending to the tip of her nose. She applied an herbal topical concoction and applied it on the affected areas. Interval history revealed gradual loss of vision on the right eye, appearance of right conjunctival redness, ptosis, and inability to move the right eye.

Patient consulted the emergency room and physical examination revealed presence of no light perception on the right eye, complete ptosis, a non-reactive pupil, and spontaneous hyphema. Neurologic exam revealed decrease in sensorium and sensorimotor weakness on the right side of the body. Neuro-imaging findings revealed presence cavernous sinus thrombosis. Lumbar tap was done revealing elevated protein and lymphocytes. Ultrasound biomicroscopy revealed normal anterior chamber structures of the right eye. She was managed as a case of Viral Meningitis secondary to Orbital Apex Syndrome secondary to Herpes Zoster Ophthalmicus. Topical Acyclovir eye gel was started, Pregabalin for pain, and intravenous Acyclovir. On the third hospital week, patient was noted to have improvement of skin lesions, resolution of hyphema, improved sensorimotor strength, and better sensorium. However, the loss of vision, ptosis, and inability to move the right eye persisted.

It is necessary to consider the possibility of Orbital Apex Syndrome development in HZO. Furthermore, properly grasping the status of viral inflammation by cerebrospinal fluid examination and MRI examination will help select a treatment method. Prompt treatment is advised so as to avoid systemic complications.