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External photographs of primary gaze (center photo) and 9 cardinal directions of gaze.
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Figure 1: External photographs of primary gaze (center photo) and 9 cardinal directions of gaze.

Mentions: At our initial examination, the patient's visual acuity was 20/20 in the right eye and 20/30 in the left eye. There was no ptosis or anisocoria in the left eye and Hertel's exophthalmometry was normal. The left eye had a mild esotropia of 8 prism diopters at primary gaze. Extraocular muscle movements were painless with restricted abduction of the left eye upon left gaze, compatible with a left CN VI palsy (fig. 1). Temporal arteries were non-palpable. Slit-lamp examination and fundoscopy were normal in both eyes, except for mild conjunctival injection. The intraocular pressure was 14 mm Hg bilaterally. Laboratory evaluation results, including erythrocyte sedimentation rate, were all within normal limits. Diffusion-weighted MRI and FLAIR sequences of the orbit and cranium were normal. There was no evidence of acute microvascular ischemic disease. Pre- and post-contrast enhancement T1 images of the orbit and sellae provided no additional clues as to the cause of the ophthalmoplegia.

Herpes Zoster Ophthalmicus and Lateral Rectus Palsy in an Elderly Patient

Yalcinbayir O, Yildiz M, Gunduz GU, Gelisken O - Case Rep Ophthalmol (2011)

Bottom Line: Acquired palsy of the lateral rectus presents with horizontal diplopia and has a broad differential.In suspected cases, zosteriform rash should be questioned.One should keep in mind that acquired esotropia in the elderly may sometimes present following HZO.

Affiliation: Department of Ophthalmology, Uluda─č University School of Medicine, Bursa, Turkey.

ABSTRACT
Acquired palsy of the lateral rectus presents with horizontal diplopia and has a broad differential. Herpes zoster ophthalmicus- (HZO) related cranial nerve palsy is a transient and self-limiting condition. Systemic antiviral treatment is administered in order to prevent sight-threatening complications. In suspected cases, zosteriform rash should be questioned. One should keep in mind that acquired esotropia in the elderly may sometimes present following HZO.

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