Extraocular Muscle Inflammation and Strabismus in a Patient with Zoster Ophthalmicus

A 61-year-old immunocompetent man presented with a left V1 forehead vesicular rash, eye pain, and injected conjunctiva. Despite a 2-week oral acyclovir regimen, left eye pain persisted, with facial pain and lesions returning. Examination revealed left strabismus and binocular diplopia but unremarkable magnetic resonance angiogram of the brain. Orbit magnetic resonance imaging (MRI) revealed left optic perineuritis with left inferior and medial rectus edema without any evidence of midbrain involvement either of the third nerve nuclei or third nerve bundles within the midbrain (A).