Case ReportConcurrent hyphema and orbital apex syndrome following herpes zoster ophthalmicus in a middle aged lady

- Herpes zoster ophthalmicus is an uncommon clinical presentation.
- Concurrent hyphema and orbital apex syndrome are rare clinical sequelae.
- Hyphema is postulated due to auto immune vasculitis affecting iris vessel.
- Orbital apex syndrome results from occlusive vasculitis affecting vasculature of optic nerve and extraocular muscles.
- This incidence probably suggests that occlusive vasculitis occurs at more than one site in the affected dermatome.

IntroductionHyphema and orbital apex syndrome occurring concurrently in a patient with herpes zoster ophthalmicus have not been reported previously. We present a case with these unique findings and discuss the pathogenesis of these conditions and their management.Presentation of caseA 59-year-old Malay lady with underlying diabetes mellitus presented with manifestations of zoster ophthalmicus in the left eye. Two weeks later, she developed total hyphema, and complete ophthalmoplegia suggestive of orbital apex syndrome. She was treated with combination of intravenous acyclovir and oral corticosteroids, and regained full recovery of ocular motility. Total hyphema persisted, and she required surgical intervention.DiscussionHyphema is postulated to occur due to an immune vasculitis affecting the iris vessels. Orbital apex syndrome is probably due to an occlusive vasculitis affecting the vasculature of the extraocular muscles and optic nerve, resulting from a direct invasion by varicella zoster virus or infiltration of perivascular inflammatory cells. Magnetic Resonance Imaging of the brain is essential to exclude possibility of local causes at the orbital apex area.ConclusionHerpes zoster ophthalmicus is an uncommon ocular presentation. Managing two concurrent complications; persistent total hyphema and orbital apex syndrome is a challenging clinical situation. Early diagnosis and prompt treatment are essential to prevent potential blinding situation.