2024 American Academy of Neurology Abstract Website

Objective:

To present a case of Herpes Zoster Ophthalmicus (HZO) sequelae of abducens nerve palsy and expected management

Background:

HZO typically involves the ophthalmic division of the trigeminal nerve. Extraocular muscle palsies are rare complications; most commonly involving the third, sixth, or fourth cranial nerves. The condition is usually self-limiting with a favorable prognosis.

Design/Methods:

N/A

Results:

74-year-old female with a history of hyperlipidemia and hypertension presented to the hospital with horizontal diplopia and blurry vision. Symptoms began 2 weeks prior and were preceded by 3-4 days of right-scalp allodynia followed by a herpetic rash in the right V1-scalp region. She initially presented to urgent care and was diagnosed with VZV, prescribed valacyclovir for 7 days, along with gabapentin for allodynia. Soon after, she developed right-eye blurry vision and horizontal diplopia. She presented to the ED after being evaluated by an ophthalmologist who was concerned for cranial nerve VI palsy. When evaluated, the patient was found to have mildly elevated inflammatory markers of ESR 35 and CRP 7.6. Neurological evaluation was significant for right abducens nerve palsy along with binocular horizontal diplopia on primary and right end gaze. Crusting was noted along the right V1 peri-orbital distribution. Fundoscopy and CTA head and neck showed unremarkable pertinent acute findings. MRI brain and orbits was unremarkable for any acute pathology without enhancement of the bilateral abducens nerves. Patient was ultimately given conservative treatment for HZO with patching of her eye and gabapentin for pain relief. Since discharge, she had complete resolution of her diplopia and vision at her follow-up visit.

Conclusions:

While there’s a broad differential for CN 6 palsy, one should consider it in the setting of HZO. In this specific case, the patient had presented with HZO more than 72 hours after her lesions crusted and shingles treatment, thus conservative therapies were appropriate.