High-Resolution MRI for Early Diagnosis of Orbital and Neurovascular Involvement in Herpes Zoster Ophthalmicus

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.