Orbital Apex Syndrome: a rare complication of herpes zoster ophthalmicus in a Ghanaian woman living with HIV

Abstract

Herpes Zoster Ophthalmicus (HZO) usually affects the immunocompromised and aged. It results from the reactivation of latent varicella zoster infection in the trigeminal ganglia. Orbital apex syndrome (OAS) is a rare sequela of the disease and tends to be disfiguring and vision-threatening if not addressed. We report on a 43-year-old Ghanaian female living with Human Immunodeficiency Virus infection and on highly active antiretroviral therapy who presented with a 2-month history of a healed vesicular rash left side of the forehead and a droopy left upper eyelid. On examination, she had complete ptosis, visual acuity in the left eye was 6/36, and restricted mobility in all directions of gaze. On anterior segment examination using a slit lamp biomicroscope, the left eye had mild cornea oedema with keratic precipitates and relative afferent pupillary defect (RAPD). Intraocular pressure and posterior segment of the right eye were normal. Computed tomography (CT) Scan of the head was taken to rule out other causes of OAS. Patient was treated with oral acyclovir 400mg five times daily for 30 days, topical steroids and oral prednisolone 60mg daily for 30 days which was tapered. Ptosis improved significantly with mild supraduction and infraduction deficit. Visual acuity improved to 6/12 and all keratic precipitates cleared. The patient, however, developed a corneal scar from a possible neurotrophic ulcer after defaulting treatment for 11 months. OAS , as a rare sequalae of HZO, responds well to oral acyclovir and steroids. Prompt diagnosis and appropriate treatment, even at late presentation, yield positive outcomes.

Funding: None declared.

Keywords: Acyclovir; Herpes Zoster Ophthalmicus; Human Immunodeficiency Virus; Orbital Apex Syndrome; Prednisolone.

Figure 1

An image of the patient at presentation

Figure 2

Image of the patient 12 months after treatment initiation