Study: Herpes zoster ophthalmicus in healthy children often has good prognosis

A study of 10 otherwise healthy children with herpes zoster ophthalmicus found that nine of them achieved good visual acuity at their last visit, despite some degree of abnormal corneal sensitivity and corneal opacity.

Denise de Freitas

“This persistent hypoesthesia suggests permanent nerve and ganglion damage,” said Denise de Freitas, MD, from the department of ophthalmology of the Federal University of São Paulo, Brazil, and colleagues in the American Journal of Ophthalmology. “Corneal sensitivity is decreased more frequently and severely in varicella zoster when compared with herpes simplex infection.”

Patients 15 years of age and younger with herpes zoster ophthalmicus were included in the study from January 1999 to January 2005. The mean age of the 10 children (five boys, five girls) at presentation was 8.7 years (range, 2 to 14 years). None of the children appeared to have any systemic disease nor a history of varicella vaccination. Six children, though, had a reported history of varicella.

Skin lesion location

Three patients presented with skin lesions that were limited to the frontal nerve dermatome, and seven cases involved the nasociliary dermatome.

In one female patient, all three branches of the trigeminal nerve were compromised. Oral candidiasis was also detected in this patient, who was treated with topical nystatin. The patient underwent three systemic evaluations: at initial presentation of the disease, 2 months and 6 months. Although the child was followed for 15 months, no systemic disorder was detected.

In the acute phase, conjunctival hyperemia, punctate keratitis and eyelid swelling were observed in all 10 patients. Five patients presented with mild interstitial keratitis, and two patients with severe iritis associated with severe interstitial keratitis. Corneal sensitivity was abnormal in all patients during the acute phase. There were no cases of microdendrite.

Diagnosis of herpes zoster ophthalmicus occurred within 72 hours of eruptions. Systemic acyclovir was either intravenously or orally, until the scabbing of lesions. Topical corticosteroids or antibiotics were administered only if necessary, and no patient received systemic corticosteroids.

Noncompliance

The median duration of systemic antiviral treatment was 10 days (range, 8 to 14 days). However, two patients did not adhere to the drug regimen. One of these patients did not use any medication and the other used only half of the prescribed dose during the first 8 days of treatment.

Patients were followed for a mean duration of 19 months (range, 8 to 78 months), and eight patients were followed for more than 12 months.

At last visit, two patients had decreased visual acuity. These were the two patients who did not adhere to their drug regimen. The patient who used only half the prescribed dose also had corneal anesthesia with a recurrent neurotrophic ulcer. “He eventually developed a vascularized corneal leukoma with calcification and superficial irregularities,” the authors said.

The other non-adherent patient developed total corneal opacification and secondary angle-closure glaucoma, which led to amaurosis.

Corneal sensitivity

Nine patients had decreased corneal sensitivity at last visit, and five exhibited some degree of corneal opacity. There was also total resolution of altered ocular motility in two patients.

The study underscores the fact that childhood zoster is not necessarily associated with an underlying immunodeficiency, malignancy or HIV infection, the authors said.

There have also been some case reports of zoster in children after varicella vaccination, some of which were caused by a wild varicella zoster or vaccine strain varicella zoster.

“The differential diagnosis in herpes zoster patients should include herpes simplex infection and impetigo, contact dermatitis, chemical burn and insect bites,” the authors said.

Clinical diagnosis

A painful red eye, most often caused by keratitis or uveitis, is how ocular involvement with herpes zoster ophthalmicus presents clinically. Other forms of eye involvement include acute hemiplegia, sclerokeratitis with anterior uveitis, central retinal artery occlusion and optic atrophy. Glaucoma secondary to uveitis in herpes zoster ophthalmicus has also been reported.

The authors noted that a high-dose systemic antiviral has a poor and variable bioavailability that requires a frequent dosing schedule. This can lead to compliance issues, as shown in the current study. Therefore, children with herpes zoster ophthalmicus may be more effectively treated by intravenous acyclovir than liquid form.

Famciclovir or valacyclovir would be better choices, the authors said, but neither drug is approved for use in children.

For more information:

Elisabeth N. Martins, MD, the corresponding author of this study, can be reached at Rua Itapeva 518 cj 1208, CEP 01332-000 São Paulo, SP, Brazil.

Reference:

De Freitas D, Martins EN, et al. Herpes zoster ophthalmicus in otherwise healthy children. Am J Ophthalmol. 2006;142:393-399.

Bob Kronemyer is an OSN Correspondent based in Elkhart, Ind.