| 본문 : We report a 30 year old man patient with orbital apex syndrome and ophthalmoplegia associated with herpes zoster ophthalmicus(HZO). He initially presented with left eye pain and headache starting 3 days ago. Left upper eye lid swelling with conjunctival injection were present. Ductions and versions showed limitation at elevation and depression on his left eye. Initial orbital magnetic resonance imaging (MRI) showed enhancement on the left superior oblique muscle suggesting orbital myositis. On suspicion of idiopathic orbital inflammation he was hospitalized and intravenous (IV) steroid pulse therapy with Methysol®(Methylprednisolone) 250mg 4 times a day for 3 days was administered. His left eye pain and headache didn’t improve while he was discharged with a tapering dose of oral Solondo® (prednisolone) 60mg once a day. Two days after he visited the emergency room of aggravated left eyelid swelling, eye pain, decreased vision and newly developed left forehead vesicles along the first division of the trigeminal branch. His best corrected visual acuity (VA) of the left eye was 20/200. Left upper lid ptosis developed and dentritic ulcer was seen at his left cornea. He was diagnosed as HZO and hospitalized for treatment. Antiviral therapy with IV Zovirax® (acyclovir) 830mg three times a day and oral prednisolone 60mg once a day was given. His left eye showed limitation at elevation, depression and abduction and the left pupil was mid dilated, sluggish. MRI showed newly developed prominent enhancement along the left optic nerve sheath and orbital apex with mild asymmetric swelling of the left four rectus muscles and superior oblique muscle. He was diagnosed as orbital apex syndrome and by his clinical course we assumed that the cause was most likely HZO. Treatment of IV acyclovir was administered for 15 days and oral prednisolone tapering was done. The left eye VA, upper lid ptosis, ophthalmoplegia gradually resolved. MRI showed improvement of soft tissue infiltration with enhancement at left optic nerve sheath, intraconal space, and orbital apex. At the most recent outpatient clinic, his left eye VA was 20/20 and upper lid ptosis, ophthalmoplegia fully recovered.
As HZO has variable initial symptoms, patients with eyelid swelling and myositis should be included as a differential diagnosis for HZO with careful examination. |