Highlights
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High-resolution MRI detects a wide spectrum of orbital and neurovascular complications in acute HZO.
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Retrobulbar and perioptic meningeal enhancement is frequent but often underrecognized.
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Oculomotor myositis is frequent in HZO patients with ophthalmoplegia.
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High-resolution DWI enables identification of ischemic optic neuropathy, differentiating it from inflammatory neuritis.
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Vessel-wall imaging reveals large-vessel vasculopathy, guiding targeted therapeutic management.
PURPOSE
To characterize high-resolution MRI (HR-MRI) findings of orbital, cranial nerve, and vascular involvement in herpes zoster ophthalmicus (HZO), and to distinguish inflammatory from ischemic patterns in patients with acute neuro-ophthalmologic symptoms.
DESIGN
Retrospective, single-center observational case series.
METHODS
Immunocompetent, PCR-confirmed HZO patients referred to a tertiary center between January 2016 and June 2025 for HR-MRI due to neuro-ophthalmologic complaints were included. Exams were performed on 3T systems using 3D FLAIR, TOF angiography, DWI, axial T2, coronal T2 STIR, and postcontrast fat-saturated 2D/3D T1 sequences, including vessel-wall assessment.
RESULTS
Twenty patients were included (median age 77.5 years). Oculomotor disorders were the most common neuro-ophthalmologic manifestation (70%). HR-MRI showed optic perineuritis (OPN) in 60%, retrobulbar episcleral inflammation in 45%, associated with orbital fat infiltration. Extraocular muscle inflammation consistent with myositis was present in most patients with ophthalmoplegia. Cavernous sinus enhancement extended to the cisternal segments of CN V, III, VI in approximately 25% of patients. Optic neuropathy was identified in 10% with diffusion restriction suggesting ischemia. Vessel-wall enhancement consistent with VZV vasculopathy affected the superficial temporal artery in 40% and the supraclinoid ICA in three patients; one had acute stroke. MRI impacted short- and long-term management in 14/20 patients.
CONCLUSIONS
In HZO with neuro-ophthalmologic deficits, HR-MRI frequently reveals perineuritis, myositis, cavernous sinus pachymeningitis, cranial nerve inflammation, and small- or large-vessel vasculopathy. Imaging helps differentiate inflammatory from ischemic complications and supports timely, tailored antiviral and adjunctive therapies. Early HR-MRI, including vessel-wall sequences, should be considered in severe or atypical HZO presentations.
INTRODUCTION
P rimary infection with varicella-zoster virus (VZV) typically occurs in childhood and manifests as chickenpox (varicella). Following primary infection, VZV remains latent in the sensory neurons of the dorsal root ganglia or cranial nerve ganglia. ,, As cell-mediated immunity declines with advancing age or immunosuppression, viral reactivation may occur, leading to herpes zoster (shingles). ,
The lifetime risk of herpes zoster is approximately 25% in the general population and increases to nearly 50% in individuals over 85 years of age. , Among cranial nerves (CN), the ophthalmic branch (V1) of the trigeminal nerve (CN V) is the most frequently affected, followed by the facial nerve (CN VII). Reactivation in the V1 branch results in herpes zoster ophthalmicus (HZO), which carries a high risk of acute and chronic complications, notably postherpetic neuralgia. , The annual incidence of HZO is estimated at 30.9 [25.9-36.6] cases per 100,000 inhabitants, with age-dependent variations related to recent vaccination coverage. , Ocular complications may occur within the first weeks following rash onset and are reported in up to 50% of untreated cases, rising to 80% when Hutchinson’s sign is present.
The diagnosis of HZO is usually clinical, based on characteristic cutaneous lesions and ocular manifestations, requiring prompt antiviral therapy to limit viral replication. In some cases, systemic or local corticosteroids may be indicated to reduce inflammation. Imaging is rarely performed when clinical features are typical. Consequently, the recent literature consists mainly of case reports ,,,,,,,,, and a single retrospective series, in which MRI was mostly requested to evaluate severe complications of ophthalmic zoster or to rule out differential diagnoses.
In recent years, MRI has become increasingly accessible—even in emergency settings—leading to broader use in neuro‑ophthalmology. High-field MRI now enables detailed evaluation of brain and orbital structures. Furthermore, vessel wall imaging (VWI) techniques allow better characterization of the arterial wall inflammation. ,,,, High-resolution MRI (HR-MRI) sequences may therefore refine assessment of orbital, peri‑orbital inflammation and vasculopathy in HZO.
The objectives of this study were to characterize the HR-MRI features of HZO-related brain and orbital involvement using dedicated high-resolution sequences and to distinguish inflammatory from ischemic MRI patterns. To achieve this, we conducted a retrospective review at a tertiary ophthalmology referral center, analyzing brain and orbital MRI findings in patients with suspected HZO-related neuro-ophthalmic complications.
MATERIAL AND METHODS
We retrospectively reviewed the medical records of all patients referred from the emergency department of the Hôpital National de la Vision des Quinze-Vingts between January 2016 and June 2025 for ophthalmologic complaints associated with herpes zoster ophthalmicus (HZO). Only patients with a positive polymerase chain reaction (PCR) test for varicella-zoster virus (VZV) DNA from tear samples or ocular swabs were included. To ensure cohort homogeneity, the study population was restricted to immunocompetent individuals, representing the most common profile of patients affected by HZO. All patients were informed and did not oppose the retrospective use of their anonymized data. The study adhered to the tenets of the Declaration of Helsinki and received approval from the Ethics Committee of the French Society of Ophthalmology (IRB 0 0008855).
Demographic characteristics, the interval between HZO onset and MRI, and clinical presentations were systematically extracted from the medical records. Imaging datasets included high-resolution brain and orbital MRI examinations performed during the acute phase of HZO. When available, clinical and radiological follow-up data enabled detailed assessment of post-treatment evolution.
All MRI examinations were performed on 3-Tesla systems (Skyra from 2016 to 2021; Prisma from 2022 to 2025, Siemens Healthcare, Erlangen, Germany) using a 64-channel head and neck coil to ensure optimal signal-to-noise ratio and high-quality image acquisition. The emergency MRI protocol included 3D SPACE FLAIR with fat saturation (FS), 3D time-of-flight (TOF) angiography, high-resolution axial diffusion-weighted imaging (DWI), axial T2 TSE, and high-resolution coronal T2 STIR focused on the orbits. Contrast-enhanced (CE) MRI, performed after intravenous gadolinium administration, consisted of high-resolution axial 2D T1 FS TSE and 3D SPACE T1 FS sequences. Detailed acquisition parameters for all high-resolution MRI sequences are provided in Table 1 .
TABLE 1
MRI Acquisition Parameters.
| 2D Sequences | TR/TE/TI (ms) | FOV (mm) | Voxel size (mm3) | Flip Angle (°) |
|---|---|---|---|---|
| T1 FS | 500/7.3/- | 200 × 200 | 0.2 × 0.2 × 2.5 | 90 |
| T2 | 4580/95 | 200 × 240 | 0.3 × 0.3 × 3 | 90 |
| T2 STIR | 8290/94/220 | 165 × 180 | 0.2 × 0.2 × 2.5 | 90 |
| DWI (b0; b1000) | 5500/55/- | 230 × 230 | 0.7 × 0.7 × 3.5 | 90 |
| 3D sequences | ||||
|---|---|---|---|---|
| FLAIR | 5000/381/1600 | 192 × 256 | 0.5 × 0.5 × 1.1 | 90 |
| T1 FS | 700/18 | 230 × 230 | 0.9 × 0.9 × 0.9 | 90 |
| TOF | 18/4 | 220 × 220 | 0.4 × 0.4 × 0.5 | 20 |
Two board-certified neuroradiologists (SE and THN), with over five years of radiology experience, independently reviewed all MRI studies while blinded to the initial clinical imaging reports. All examinations were de-identified, and readers were unaware of the acquisition protocols during assessment. A consensus reading was obtained after comparison of individual evaluations. In cases of disagreement, a third senior neuroradiologist (FL) provided adjudication. Given the retrospective design and small sample size, statistical analyses were primarily descriptive. Continuous variables—such as patient age and the interval between symptom onset and MRI—were summarized using medians, ranges, and SDs. Categorical variables—including sex, laterality, clinical manifestations, and radiological findings—were reported as frequencies and percentages.
RESULTS
The demographic, clinical, and radiologic characteristics of the 20 included patients are summarized in Table 2 . The median age was 77.5 years (range, 13-98; SD, 19.3), and 12 patients were male (60%). The median interval between the first HZO-related sign or symptom and referral was 12 days (range, 1-150; SD, 35.5). Left-sided involvement occurred in 14 patients (70%). Beyond facial rash and/or anterior segment involvement, the most common neuro-ophthalmologic manifestation was an oculomotor disorder—complete ophthalmoplegia, proptosis, or CN III/VI paresis—present in 14 patients (70%). No clinical CN IV palsy was identified. Four patients presented with vision loss. One was referred for facial nerve palsy, and another for a painful orbital rash suggestive of VZV reactivation.
TABLE 2
Demographic, Clinical and Radiologic Data.
| Demographics | ||
|---|---|---|
| Age in years, (median [IQR], standard deviation) | 77.5 [13-98] | 19.3 |
| Male gender, number (%) | 12 | 60% |
| Delay from the onset of HZO in days (median [IQR]), standard deviation) | 12 [1-150] | 35.5 |
| Affected side | 6 right/ 14 left | 30% right/ 70% left |
| Clinical features | Patients | Ratio |
| Vision loss | 4 | 20% |
| Ophthalmoplegia/ CN III or CN VI paresis/ ptosis | 14 | 70% |
| Facial nerve palsy | 1 | 5% |
| Orbital pain | 1 | 5% |
| MRI findings | ||
| Eyelid swelling | 17 | 85% |
| Conjunctival edema | 9 | 45% |
| Uveal enhancement | 9 | 45% |
| Retrobulbar fat enhancement | 9 | 45% |
| Extraocular myositis | 12 | 60% |
| Orbital fat enhancement | 12 | 60% |
| Optic nerve (ON) STIR hyperintensity | 2 | 10% |
| ON DWI restriction | 2 | 10% |
| Optic perineuritis (OPN) | 12 | 60% |
| Orbital CN III enhancement | 5 | 25% |
| Nerve V1 enhancement | 7 | 35% |
| Nerve V2 enhancement | 3 | 15% |
| Nerve V3 enhancement | 1 | 5% |
| Orbital apex enhancement | 10 | 50% |
| Cavernous sinus enhancement | 11 | 55% |
| Cisternal CN V enhancement | 5 | 25% |
| Cisternal CN III enhancement | 4 | 20% |
| Cisternal CN VI enhancement | 4 | 20% |
| Cisternal CN VII enhancement | 1 | 5% |
| Superficial temporal artery wall enhancement | 8 | 40% |
| Intracranial meninges enhancement | 11 | 55% |
| Acute stroke | 1 | 5% |
One pregnant patient did not undergo contrast injection but had complete pre-contrast MRI sequences. In two patients, postcontrast evaluation was limited due to motion artifacts. Accordingly, retrospective review relied exclusively on noncontrast images for these three individuals and was complete in the remaining 17. Eyelid edema was present in 17 patients. Uveitis-related enhancement was identified in 9 patients, including one case of choroidal detachment. Retrobulbar episcleral enhancement was observed in 9 patients, with posterior episcleral inflammatory infiltration along the posterior ciliary nerves and vessels, often contiguous with perioptic meningeal enhancement ( Figure 1 ).
A, B. Coronal STIR and axial T2 sequences in the same patient. C, D. Axial T2 and contrast-enhanced (CE) T1 fat-suppressed (FS) sequences in another patient. E, F. Axial CE T1 FS in two different patients. Palpebral soft tissue infiltration is seen (A, B, large white arrows), along with conjunctival edema presenting as fluid signal with thin mural enhancement (B, E, F, hollow arrows). The inflammatory uveal enhancement of the affected eye contrasts with the fellow eye and is associated with posterior episcleral enhancement along the posterior ciliary nerves and vessels (E, F, arrows). In one patient, a complete choroidal detachment observed on slit-lamp examination was visible on pre-contrast sequences (C, arrows), showing intense enhancement (D, arrows).
Perioptic meningeal enhancement (optic perineuritis, OPN) was identified in 12 patients (60%) ( Figure 2 ). OPN exhibited variable patterns, including focal retrobulbar involvement, diffuse enhancement along the entire optic nerve sheath, or enhancement confined to the orbital apex adjacent to vascular wall inflammation. OPN was more frequent than optic neuritis in this cohort, and high-resolution STIR and contrast-enhanced T1-weighted sequences reliably distinguished meningeal from intraneural signal abnormalities.
