Case Report

Complete Recovery of Herpes Zoster-Associated Isolated Oculomotor Nerve Palsy without Systemic Steroids

Alma Sabic*, Alexandra Fritz, Robert Müllegger

Department of Dermatology, State Hospital Wiener Neustadt, Austria

*Corresponding author: Alma Sabic, MD Corvinusring 3-5AT-2700, Wiener Neustadt, Austria

Received Date: 15 May 2023

Accepted Date: 24 May 2023

Published Date: 29 May 2023

Citation:Sabic A, Fritz A, Mullegger R, (2023) Complete Recovery of Herpes Zoster-Associated Isolated Oculomotor Nerve Palsy without Systemic Steroids. Clin Exp Dermatol Ther 8: 207. https://doi.org/10.29011/2575-8268.100207

Key Points

Question

What ist the role of systemic steroids in the treatment of herpes zoster-associated oculomotor nerve palsy?

Findings

ONP was present in 5/259 (1,9%) patients. Treatment consisted of intravenous aciclovir for 7-21 days at a daily dosage of 5-10mg/kg body weight. Complete resolution of ONP was achieved within 10-120 days without systemic corticosteroids.

Meaning

The routine use of steroids does not appear to be mandatory in the treatment of herpes zoster-associated oculomotor nerve palsy.

Abstract

Backgrounds: Ophthalmoplegia is an infrequent complication of Herpes zoster ophthalmicus (HZO) that is caused by involvement of the oculomotor and/or the abducens-, and trochlear nerves. The use of corticosteroids has been of inconsistent effect. Objectives: To describe the incidence, clinical characteristics, and outcome of ONP after treatment with aciclovir in a consecutive series of patients with HZO. Materials and Methods: Between January 2014 and December 2022, 259 patients with HZO were treated at the Department of Dermatology, Federal Hospital, Wiener Neustadt, Austria. ONP was present in 5/259 (1,9%) patients. The computerized charts of these five patients were scrutinized for all clinical data, comorbidities, therapy and course.

Results: The mean age of the 5 patients (f:m = 3:2) was 76.6 years. The skin lesions of herpes zoster (HZ) were limited to the dermatome of the ophthalmic nerve in all patients. The clinical appearance was stereotypical of HZ. ONP was ipsilateral and complete (i.e. total internal and external ophthalmoplegia) and it developed within few days after the start of the skin lesions. Moderate to severe pain was present in all five patients. Treatment consisted of intravenous aciclovir for 7-21 days at a daily dosage of 5-10mg/kg body weight without systemic corticosteroids. Complete resolution of ONP was achieved within 10-120 days. Conclusion: ONP is a rare complication of HZO with a good prognosis with standard treatment with nucleoside analogues. The routine use of steroids does not appear to be mandatory.

Keywords:  Herpes zoster ophthalmicus; Oculomotor nerve palsy; Complication; Therapy; Glucocorticosteroids

Abbreviations: HZ: Herpes zoster, VZV:  Varicella-zoster virus , HZO: Herpes zoster ophthalmicus , ONP: Oculomotor nerve palsy

Introduction

Herpes zoster ophthalmicus (HZO) is defined as a neurocutaneous inflammation in the dermatome served by the ophthalmic division of the trigeminal nerve that is caused by the reactivation of the varicella-zoster virus (VZV) in the trigeminal ganglion. It accounts for up to 20% of all herpes zoster (HZ) cases. Pain is prevalent in all stages of HZO, with postherpetic neuralgia affecting 5-30% of particularly elderly patients [1,2]. Involvement of the eye compounds HZO in at least 50% [1]. It comprises conjunctivitis and anterior uveitis (together accounting for three quarters of cases), stromal keratitis, scleritis/episcleritis, retinal necrosis, and optic neuritis [3]. Opthalmoplegia is an infrequent complication in the acute stage of HZO. It is most often caused by (isolated) involvement of the oculomotor nerve, with about 50 published cases [4-6], followed by the abducens and the trochlear nerve [7]. Exceptionally, more than one nerve is affected. Paralysis is partial or complete and ipsilateral to the skin lesions, although bilateral or contralateral cases may occur [7]. Ophthalmoplegia is not significantly associated with immunosuppression [9]. We present a series of five patients with oculomotor nerve palsy (ONP) out of a collective of 259 HZO patients, who all recovered completely with nucleoside analogues only without systemic steroid treatment.

Methods

Between January 2014 and December 2022, 259 consecutive in-patients with HZO were treated at the Department of Dermatology, Federal Hospital, Wiener Neustadt, Austria. The retrospective analysis of those patients revealed the diagnosis of ONP in 5/259 (1,9%) patients. The computerized charts of these five patients were scrutinized for all clinical data, comorbidities, therapy and course.

Results

Two hundred and fifty-nine cases with HZO were given inpatient treatment between January 2014 and December 2022 at the Department of Dermatology, Federal Hospital Wiener Neustadt, Austria. Five of them (1,9%), all with comorbidities, but none with immunosuppression, suffered from ONP (Table 1). Three patients were female; the mean age was 76.6 years. The skin lesions of HZ were limited to the dermatome of the first division of the trigeminal nerve (ophthalmic nerve) in all patients with no predilection of one side. The clinical appearance was stereotypical of HZ, with necrotic lesions in the two oldest patients. ONP was ipsilateral and complete (i.e. total internal and external ophthalmoplegia) in all five patients, resulting in ocular down- and outward deviation with double-vision, ptosis, and mydriasis (Figure 1A and 1B; Figure 2A and 2B). It developed within few days after the start of the skin lesions. In addition to conjunctivitis in all patients, further ocular manifestations were observed in two patients. Moderate to severe pain was present in all five patients and had to be treated with a combination of at least two medications. Additional extracutaneous complications were not present. Treatment consisted of intravenous aciclovir for 7-21 days at a daily dosage of 5-10mg/kg body weight. Complete resolution of ONP was achieved within 10-120 days.

Patient Nr.

Age (Years)

Sex

Site of herpes zoster

Dermatological findings

Time between Herpes zoster and  oculomotor nerve palsy (Days)

Initial Pain (VAS); Analgetic Therapy

Further complications

Aciclovir-Therapy

Duration of oculomotor nerve palsy (Days)

Comorbidities

1

74

m

V/1, right

moderate

10

4.5

GAB, MET

None

5mg/kg, 7 days

10mg/kg, 7 days

60

2

86

f

V/1, right

necrotizing

5

6.5

GAB, MET, PAR

Keratitis

iritis

5mg/kg, 5 days

10mg/kg, 11 days

120

St.p. stroke 08/2016

St.p. myocardial infarction

Atrial fibrillation

Arterial hypertension

Bronchial asthma

3

70

m

V/1, left

moderate, papular

11

6.5

PAR, MET

Anterior uveitis

5mg/kg, 7 days

10

Arterial hypertension

Diabetes mellitus Type II

4

76

f

V/1, left

moderate

7

7

GAB, PAR, MET, KET, PRE

None

5mg/kg, 21 days

21

Arterial hypertension

Hypothyroidism

5

77

f

V/1, left

necrotizing

7

7.5

PAR, GAB, TRAM, KET

None

5mg/kg, 10 days

42

Arterial hypertension

Bronchial asthma

Hypothyroidism

Atrial fibrillation

Abbreviations: V/1, dermatome of the first branch of the trigeminal nerve, VAS, visual analogue scale; GAB, gabapentin; MET, metamizole; PAR, paracetamol; KET, ketamine; PRE, pregabalin; TRAM, tramadol

Table 1: Clinical characteristics and therapy of 5 patients with herpes zoster ophthalmicus with oculomotor nerve palsy.


Figure 1A: 86-year old female (patient 2) with necrotizing herpes zoster ophthalmicus with ocular motor nerve palsy (shown are ptosis and down- and outward deviation of the bulb of the right eye).