Orbital Myositis after Herpes Zoster Ophthalmicus: A Case Report and a Narrative Review of the Literature

Abstract

Herpes zoster ophthalmicus results from the reactivation of the latent varicella zoster virus, affecting the first branch of the trigeminal nerve. In 20-70% of cases, Zoster Ophthalmicus can lead to ocular involvement, affecting various orbital structures. Orbital myositis is a rare but severe complication of herpes zoster ophthalmicus. We present a case of a 52-year-old man with no significant medical history who developed zoster-associated right ocular myositis and dacryocystitis. He was treated with intravenous acyclovir and oral steroids. A review of the literature identified 29 patients across 19 studies. The median age was 61 years, with a slight female predominance. In 55% of cases, the patients had no notable medical history. The most common presentation of myositis involved all oculomotor muscles. There were 22 cases who were treated with intravenous antiviral therapy and 19 received steroids. A full resolution of symptoms was achieved in 51.7% of patients. Zoster-related orbital myositis is a rare complication that should be considered even in immunocompetent individuals. It may occur either before or after the appearance of a vesicular rash. Magnetic resonance imaging is the preferred radiological exam for assessing orbital involvement. Intravenous antiviral therapy should be started within 72 h of symptom onset, and its combination with systemic corticosteroids appears to be an effective treatment for zoster-related ocular myositis.

Keywords: acyclovir; herpes zoster; myositis; shingles.

Figure 1

Flow-chart of the studies revised in the narrative review.

Figure 2

Clinical presentation at admission in hospital ward.

Figure 3

One month of follow-up after hospitalization.

Figure 4

(A,C) Transverse and Coronal T1-weighted orbit MRI of patient with altered signal intensity of right superior rectus, medial rectus, lateral rectus, and superior oblique muscles. At one-month follow-up (B,D), improvement of extraocular muscle myositis can be seen on T1-weighted transverse and coronal image of orbits.

Figure 5

HZO-related cutaneous and ocular presentations and complications.