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Elderly Man with Right Eye Pain, Rash, and Multiple Cranial Neuropathies
This case features an elderly man presenting with right eye pain, rash, and multiple cranial neuropathies involving CN III, IV, V1, and VI, ultimately diagnosed with herpes zoster ophthalmicus (HZO).
Imaging overview:
Axial and coronal T1 post-contrast fat-saturated MRI sequences demonstrate enhancement along the right optic nerve sheath complex, sclera, and periorbital soft tissues, indicated by the yellow arrows on the annotated images. Asymmetric enhancement of the right superior orbital fissure and cranial nerves within the right cavernous sinus is also identified, corresponding to the patient’s constellation of cranial neuropathies.
Clinical insight:
HZO typically presents with a unilateral burning sensation and headache along the V1 dermatomal distribution, followed by eruption of a vesicular rash. Importantly, orbital myositis is a recognized manifestation of HZO that can precede the onset of rash — meaning HZO should remain in the differential for unilateral orbital myositis even when cutaneous symptoms are not yet present. HZO carries serious vision-threatening potential, with complications including optic neuritis, acute retinal necrosis, and corneal damage in the form of neurotrophic keratosis. Early recognition and treatment are critical to preventing permanent visual morbidity.
Case courtesy of Connor Tierney, MD & Erin N. McComb, MD, Northwestern Memorial Hospital.