John works in the School of Biological Sciences at Monash University as a Professor



Herpes zoster ophthalmicus (HZO) is characterized by radicular pain and a vesicular eruption in the distribution of the ophthalmic nerve. The underlying cause is reactivation of the varicella zoster virus. The most common neurological complication of herpes zoster is post-herpetic neuralgia; however, cranial nerve palsies, meningoencephalitis, and other sequelae have been reported in rare cases (1). Herein we present a case that was initially diagnosed as uncomplicated preseptal cellulitis, but over the ensuing days revealed HZO and multiple rare sequelae. 

Case Report:

A 57-year-old male with a history significant for cryptogenic organizing pneumonia on chronic corticosteroids presented with a left fronto-parietal headache and swelling of his left upper and lower eyelids for four days. He denied any visual symptoms, fevers, or other complaints. His physical exam revealed marked periorbital edema with mild associated tenderness. There was no overlying rash, lesion, or erythema. There was some thin, watery eye discharge. After opening the left eye further, one could see his pupils were equal, round, and reactive and he had full extraocular movements without pain. His visual acuity was intact. Routine labs including a complete blood cell count were unremarkable. A computed tomography (CT) scan revealed the edema was limited to the preseptal soft tissues. He was begun on intravenous clindamycin for preseptal cellulitis and admitted to the hospital.

On hospital day 2, vesicles emerged in the V1 dermatome, including the tip of the nose. This was concerning for Hutchinson’s sign for HZO. He was started on intravenous acyclovir, and antibiotic coverage was escalated to vancomycin and piperacillin-tazobactam for broad coverage of bacterial superinfection. Over the next few days, his pain and swelling improved, the vesicles scabbed over, and the switch to oral antimicrobials was imminent.

However, on hospital day 5, the patient was keeping one eye closed to combat dizziness, and complained of seeing double. Physical exam revealed a new left-sided lateral rectus palsy. Magnetic resonance imaging (MRI) of the brain and orbits was obtained which showed a filling defect in the lateral aspect of the left cavernous sinus suggestive of thrombus.


This immunocompromised patient who was found to have corneal-sparing HZO subsequently developed an abducens nerve palsy. Rare case reports have documented this occurrence (4). After obtaining the MRI and discussing the case with the neuroradiologist, a careful look at the images revealed evidence of thrombus in three images of the series. It is unclear exactly when this developed during his clinical course.

Sixth nerve palsies have previously been reported in the setting of cavernous sinus thrombosis as well as in the setting of V1 zoster alone. Extraocular muscle palsies associated with both HZO (2) and with cavernous sinus disease (3) are usually a transient and self-limited phenomenon.