Herpes Zoster Ophthalmicus with Isolated Paralytic Mydriasis

Introduction: Herpes zoster ophthalmicus occurs when there is a reactivation of herpes 3 lying latent in the ophthalmic division of the trigeminal nerve. We report a case of an 86 year-old female patient with an orbital cellulitis with post-septal involvement admitted in our departement for topical and intravenous antibiotics. On the fourth day of admission vesicular lesions began to emerge in the left side of the face and scalp not exceeding the mid line and treatment for herpes zoster withoral acyclovir and topic ganciclovir was initiated. Then an anisocoria was noticed and in the left pupil the direct and consensual reflexes were abolished as well as the accommodation reflex. There was no intraocular hypertension, anterioror posterior synechiae; no external ophthalmoplegia, ptosisor diplopia. The brain CT revealed no relevant alterations. The patient was discharged after eighteen days of hospitalization, maintaining the paralytic mydriasis of the left pupil. Discussion: Isolated paralytic mydriasis as the only complication after herpes zoster ophthalmicusis extremely rare. The responsible mechanisms are notfully understood. It is thought that the cause is, among other factors, the involvement of the pupillary fibers for light and accommodationconvergence, with no damage of the motor fibers. Casal IA1*, Monteiro S1, Borges T1, Vale C1, Friande A1, Araújo M1 and Beirão JM1,2 1Centro Hospitalar do Porto – Hospital de Santo António, Portugal 2Instituto de Ciências Biomédicas Abel Salazar, Universidade Porto, Portugal Casal IA, et al. Annals of Clinical Case Reports Ophthalmology Remedy Publications LLC., | http://anncaserep.com/ 2016 | Volume 1 | Article 1082 2 of the left eye was 0.3 (decimal scale) and the right eye 0.8, without any correction. The computed tomography (CT) scan of the orbits revealed orbital cellulitis with post-septal involvement. The patient was admitted for treatment with topical of loxacin and intravenous antibiotic therapy with vancomycin 1 g bid and ceftriaxone 1 g bid. On the fourth day post admission, began to emerge vesicular lesions in the left side of the face and scalp that did not exceed the midline, being very suggestive of herpes zoster ophthalmicus. The patient presented with lesions in the tip of the nose Hutchinson's sign suggesting involvement of the nasociliary branch and greater probability of more serious ocular involvement. The remaining examination just showed mild superficial keratitis, without signs of anterior chamber inflammation, ocular hypertension or posterior segment alterations; and we began therapy with oral acyclovir 800 mg, 5 times per day and ocular topic ganciclovir q4h. On the sixth day post admission the skin lesions were improving and at different stages of evolution, there was an improvement of the face and eyelid edema, but the left pupil was almost not reactive to light, still with no signs of anterior chamber inflammation or ocular hypertension. Oral corticosteroid therapy was initiated. On the ninth day of hospitalization and despite symptomatic improvement, we objectified an anisocoria (left pupil 3 mm bigger than the right) which decreased in scotopic conditions, with the left pupil almost with no light reaction (Figure 1). Slit-lamp examination showed a mild conjunctival hyperemia and superficial keratitis in the lower half of the cornea; there were no alterations of the iris and no signs of anterior chamber inflammation, anterior or posterior synechiae. The intraocular pressure was 15/16 mmHg and the visual acuityofthelefteyedecreased to 0.1.Brain CT scan revealed ischemic leukoencephalopathy and enlargement of the cerebrospinal fluid circulation pathways by atrophy changes consistent with the age of the patient. The neurology examination showed preserved higher functions; algic hypoesthesia in the territory of the left first division of the trigeminal nerve and anisocoria described as above: both pupils were regular, and the right pupil had direct and consensual light reflexes preserved but in the left pupil, the direct and consensual light reflexes were abolished as well as the accommodation reflex. There were no external ophthalmoplegia, ptosisor diplopia (Figure 2). The patient was discharged after eighteen days of hospitalization, asymptomatic, with almost complete resolution of the skin and scalp lesions and no eyelid edema. She completed 13 days of intravenous therapy with vancomycin and ceftriaxone; 14 days of oral acyclovir and topical ganciclovir and 11 days of oral corticosteroid therapy. Currently, six months after discharge, the patient has a visual acuity of the left eye of 0.3; the slit lamp examination shows only a slight posterior capsule opacification and maintains the anisocoria with paralytic mydriasis of the left pupil.