Increased neuro-ophthalmic manifestations of herpes zoster infection incidence: A 14-year cohort study from a tertiary medical center

PURPOSE: This study aimed to evaluate the spectrum and incidence of neuro-ophthalmic complications of herpes zoster (HZ) over 14 years at a large tertiary medical center. DESIGN: Retrospective cohort study. METHODS: The study included patients with a confirmed diagnosis of HZ who presented to the neuro-ophthalmology clinic with cranial nerve 3/4/6 involvement, optic disc edema, abnormal cerebrospinal fluid, or imaging findings suggestive of meningoencephalitis. Demographic, clinical, imaging, and outcome data were manually collected from electronic medical records. For comparative analysis, data were aggregated into two periods: 2006-2012 and 2013-2020. RESULTS: Seventeen patients with neuro-ophthalmic complications were identified. The mean age at presentation was 67 years, and 76% were male. Autoimmune disease was present in 35% of patients, malignant disease in 29%, and 24% were receiving immunosuppressive therapy at HZ onset. Only one patient had documented prior Varicella zoster vaccination. Neuro-ophthalmic manifestations included visual field defect (53%), diplopia (53%), ptosis (47%), and post-herpetic neuralgia (41%). At the end of follow-up, 18% achieved complete recovery, 65% partial improvement, and 12% showed no improvement. The vast majority of patients (82%) presented in 2013-2020, with the incidence increasing from 0.1% of new clinic patients in 2006-2012 to 0.3% in 2013-2020 ( P < 0.05). CONCLUSION: Neuro-ophthalmic manifestations of HZ appear to be increasing, predominantly affect older males, and frequently result in incomplete recovery. Limited neuroimaging findings highlight the primacy of clinical assessment. Larger prospective studies are needed to clarify risk factors and improve management.