Total Ophthalmoplegia as an Early Manifestation of Herpes Zoster Ophthalmicus in an Elderly Patient With Asthma: A Case Report.

Herpes zoster ophthalmicus (HZO) may cause ocular surface disease, but ocular motor cranial neuropathy and total ophthalmoplegia are rare. These neurological deficits generally develop after the cutaneous eruption, making their presence at initial presentation unusual. Asthma has recently gained attention as a risk factor for herpes zoster, potentially through Th2-skewed inflammation, relative Th1-mediated antiviral immune insufficiency, and impaired cellular control of latent varicella-zoster virus (VZV). We report a 71-year-old man with poorly controlled asthma who presented with a one-day history of a right-sided vesicular eruption following four days of severe burning pain in the right scalp and periorbital region. Total ophthalmoplegia was already present at initial evaluation. He had no known diabetes mellitus, hypertension, malignancy, systemic immunosuppression, recent infection, biologic therapy, or chronic systemic corticosteroid use. His only notable comorbidity was asthma, for which fluticasone furoate/umeclidinium/vilanterol had been prescribed, although he used it irregularly. The right eye was fixed, with total ptosis, absent spontaneous movement, and marked restriction in all gaze directions. Presenting uncorrected visual acuity was 0.3 in the right eye and 0.8 in the left eye using decimal notation, and anisocoria was present with absent direct and consensual light reflexes. The diagnosis of HZO was clinical; VZV polymerase chain reaction testing was not performed because of the characteristic painful unilateral vesicular eruption in the ophthalmic dermatome. Contrast-enhanced orbital magnetic resonance imaging was normal, and laboratory evaluation did not reveal any other systemic risk factor, including a negative HIV and viral hepatitis panel. The patient received intravenous acyclovir at 10 mg/kg every eight hours for 21 days, with daily renal function monitoring, as well as a short course of methylprednisolone and topical dermatologic and ophthalmologic therapies. The cutaneous lesions regressed, and the corneal epithelial defect closed; however, complete ptosis and ophthalmoplegia persisted, and visual acuity remained the same as the baseline in both eyes at the fourth-week follow-up. This case demonstrates that total ophthalmoplegia may be present at the initial presentation of HZO. Advanced age was the patient's major established risk factor, while asthma was his only chronic comorbidity. Asthma may represent a contributing clinical context, but a causal relationship with complicated HZO cannot be inferred from a single case.