(CR38) Double Sword: Simultaneous Optic Neuritis and Trochlear Nerve Palsy in Herpes Zoster Ophthalmicus

Introduction:

Herpes Zoster optic neuritis is a rare presentation of Herpes Zoster Ophthalmicus (HZO) and potentially blinding condition. This is a rare case of simultaneous optic neuritis and trochlear nerve palsy in HZO.

Case Presentation :

16-years-old girl, presented with vesicles on right forehead, eyelids and nasal bridge for 2 weeks, followed by right eye redness and photophobia. She was treated for HZO anterior uveitis with topical steroids, topical acyclovir and oral acyclovir. Her symptoms improved with treatment but she experienced worsening of the right eye vision after 1 week. Right eye visual acuity was 6/36 with positive Relative Afferent Pupillary Defect. Fundus examination reveals right eye optic disc swelling and visual field examination showed enlarged blind spot. Extraocular muscle movement examination showed right hypertropia and limited intortion. A diagnosis of optic neuritis and right trochlear nerve palsy was made.  Pulse methylprednisolone was started along with intravenous acyclovir for 5 days, and she completed a total course of 6 weeks of oral acyclovir and prednisolone. 2 months later, her right eye vision had improved to 6/12. There was total resolution of optic neuritis, anterior uveitis and trochlear nerve palsy.

Conclusion :

Early diagnosis and prompt management of optic neuritis and trochlear nerve palsy in HZO leads to good prognosis and recovery.