Role of Magnetic Resonance Imaging in Herpes Zoster Ophthalmicus Ophthalmoplegia

Aims: To hypothesize the mechanisms of herpes zoster ophthalmicus (HZO) related ophthalmoplegia by magnetic resonance imaging (MRI).

Case Presentation: A 61-year-old Chinese man diagnosed with right sided HZO and a positive Hutchinson’s sign, subsequently developed right eye complete ptosis, mydriasis and limitation of elevation 1 month after the onset of HZO. MRI showed thickening and enhancement of right oculomotor nerve and enhancement of right extraocular muscles. CSF revealed leukocytosis and positive varicella zoster virus (VZV) DNA without any clinical signs of meningitis. The diagnosis HZO-related ophthalmoplegia and asymptomatic VZV meningitis was made based on the clinical and laboratory findings. The external ocular muscle palsies of this patient were due to both oculomotor nerve palsy and orbital myositis demonstrated by MRI.

Conclusion: The pathogenesis of HZO associated ophthalmoplegia is attributed to multiple factors such as neuritis of the cranial nerve and orbital myositis which can be diagnosed with MRI.