A case of herpes zoster ophthalmicus with isolated trochlear nerve involvement.

Abstract

Herpes zoster ophthalmicus (HZO) can involve the oculomotor nerve; however, isolated trochlear nerve palsy has rarely been reported.
An 83-year-old man who suffered from HZO in the right frontal area and scalp subsequently developed vertical diplopia and severe pain. Cerebrospinal fluid examination and brain MRI revealed no abnormalities. Isolated right trochlear nerve palsy was diagnosed based on the findings of neuro-ophthalmological tests.
Isolated trochlear nerve involvement associated with HZO is very rare and may be easily overlooked. Physicians should carefully examine oculomotor involvement in HZO.

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Copyright © 2011 Korean Neurological Association 47
Print ISSN 1738-6586 / On-line ISSN 2005-5013
10.3988/jcn.2011.7.1.47
CASE REPORT
J Clin Neurol 2011;7:47-49
A Case of Herpes Zoster Ophthalmicus
with Isolated Trochlear Nerve Involvement
Key-Chung Park, Sung-Sang Yoon, Jeong-Eun Yoon, Hak-Young Rhee
Department of Neurology, Kyung Hee University School of Medicine, Seoul, Korea
Received? July 13, 2009
Revised?October 13, 2009
Accepted? October 13, 2009
Correspondence
Key-Chung Park, MD, PhD
Department of Neurology,
Kyung Hee University
School of Medicine,
1 Hoegi-dong, Dongdaemun-gu,
Seoul 130-702, Korea
Tel +82-2-958-8447
Fax +82-2-958-8490
E-mail kcpark67@medimail.co.kr
BackgroundzzHerpes zoster ophthalmicus (HZO) can involve the oculomotor nerve; however,
isolated trochlear nerve palsy has rarely been reported.
Case ReportzzAn 83-year-old man who suffered from HZO in the right frontal area and scalp
subsequently developed vertical diplopia and severe pain. Cerebrospinal fluid examination and
brain MRI revealed no abnormalities. Isolated right trochlear nerve palsy was diagnosed based
on the findings of neuro-ophthalmological tests.
ConclusionszzIsolated trochlear nerve involvement associated with HZO is very rare and may
be easily overlooked. Physicians should carefully examine oculomotor involvement in HZO.

J Clin Neurol 2011;7:47-49
Key Wordszz cranial nerve involvement, herpes zoster ophthalmicus, trochlear nerve.
Introduction
Herpes zoster ophthalmicus (HZO) causes diverse ocular and
central nervous system lesions. In HZO, the reported incidence
of extraocular muscle palsies has ranged between 7% and
31%,1-4 but many cases are asymptomatic because the diplopia
is observed in the extreme of gaze and visual acuity is decreased
in the affected eye.4 The oculomotor nerve is most commonly
affected, followed by the abducens nerve; the trochlear nerve
appears to be the least frequently involved.3-6
We report herein the case of a man who suffered from HZO
in the right frontal area and scalp, and who subsequently devel-
oped vertical diplopia due to isolated trochlear nerve palsy.
Case Report
An 83-year-old man with a 14-year history of controlled hyper-
tension and diabetes presented to our emergency room with acu-
te confusion. Five days previously a vesicular eruption and lan-
cinating pain had developed over the distribution of the oph-
thalmic branch of the trigeminal nerve on the right side of the
forehead; the headache was treated with oral acetaminophen.
On examination, his blood pressure was 170/90 mmHg and his
body temperature was 36ºC. A neurological examination dem-
onstrated reduced wakefulness associated with time, place, and
person disorientation. The cranial nerves, and sensory and mo-
tor functions were all normal, and no meningeal irritating signs
were detected. Deep tendon reflexes were symmetrically nor-
mal and Babinski’s sign was not observed. The results of rou-
tine laboratory tests were normal, with the exception of an el-
evated fasting blood glucose level of 252 mg/dL. Brain com-
puted tomography and MRI revealed no abnormalities.
Cerebrospinal fluid examination was normal with the excep-
tion of increased levels of varicella zoster virus IgG and IgM.
The patient was started on intravenous acyclovir at 1,500 mg/
day. His blood pressure ranged from 190/100 to 230/110
mmHg during the 24 hours after admission. After adding anti-
hypertensive agents the patient’s drowsiness and disorientation
were markedly improved, and he was alert and able to answer
correctly in response to queries about recent events. Howev-
er, the dose of acyclovir was changed to 1,000 mg/day orally
2 days later because his serum creatinine levels rose to 1.6 mg/
dL and he complained of difficulty urinating and swelling of
the lower extremities.
Two weeks after the vesicular eruption appeared on the right
side of his forehead, the patient complained of vertical diplopia
when he looked in the left lower direction. The diplopia was not
observed with other directional eye movements. Ophthalmolog-

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Herpes Zoster Ophthalmicus with Isolated Trochlear Nerve Palsy
48 J Clin Neurol 2011;7:47-49
ic examination revealed his visual acuity to be 20/25 in each
eye, and no visual field defects were noted on the Goldmann
perimeter. His pupils were isocoric, with prompt and symmet-
rical light reflexes. The right eye showed a severe inferior obli-
que overaction and underaction of the superior oblique muscle.
The hypertropia increased on leftward gaze (Fig. 1). The Biel-
schowsky three-step head-tilt test disclosed isolated right su-
perior oblique palsy, and the prism cover-uncover test showed
right exodeviation of 10 prism diopters (PD) on near fixation
and right hypertrophy of 4 PD on far fixation. Left side down-
ward gaze caused right hypertrophy of 6 PD, and tilting toward
the right side produced right hypertrophy of 6 PD. Routine lab-
oratory tests and brain MRI were performed repeatedly but no
abnormal findings were observed. The patient was not pre-
scribed acyclovir or steroid. A follow-up examination per-
formed 4 weeks later found that the trochlear nerve palsy had
not improved.
Discussion
The extraocular muscle palsy associated with HZO is usually
seen in the elderly and is a self-limiting condition.4 In HZO, ex-
traocular muscle palsy occurs within 1-2 weeks after the appea-
rance of skin lesions and improves significantly within 2 mon-
ths in most cases.7 However, it has been reported that the du-
ration of diplopia can vary from 2 to 23 months.7
HZO is commonly associated with ocular complications such
as keratitis, iridocyclitis, muscular palsies, and optic neuritis in
approximately half of cases.8 However, isolated trochlear nerve
palsy is very rare in HZO,5,6,9 and vertical double vision is fre-
quently asymptomatic due to the diplopia that is present only in
the extremes of gaze or decreased visual acuity of the affected
eye in many cases.2,6 In our case it was necessary to discrimi-
nate involvement of the inferior rectus muscle. In inferior rec-
tus paralysis the hypertropia is observed in the primary gaze,
with looking to the right and down increasing the hypertrophy.
The pathogenetic mechanism underlying extraocular muscle
palsy in HZO is not clear and several hypotheses have been
proposed. First, a virus may cause a direct cytopathic effect or
allergic response in the nervous tissue.10 Second, occlusive vas-
culitis may induce the cranial neuropathy.11 Third, a myositic
cause is another possible mechanism.12
While the treatment of extraocular muscle palsy associated
with HZO has not been formally investigated, the administra-
tion of antiviral agents or systemic steroid has been suggested.13
However, since the paralytic lesions improve spontaneously
and satisfactorily in some cases, the necessity for any specific
treatment is equivocal.14 One prospective study found that ad-
ministering acyclovir during the early course of HZO could pre-
vent the ocular complication.15
Ophthalmoplegia associated with HZO is not uncommon, but
isolated trochlear nerve involvement is very rare and can be
overlooked. Physicians should carefully examine oculomotor
involvement in HZO.
Conflicts of Interest
The authors have no financial conflicts of interest.
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Fig. 1. Nine gaze eye positions. The ran-
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adduction, with inferior oblique overac-
tion of the right eye.

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www.thejcn.com 49
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