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Editor,—Unifocal choroiditis occurs in children and adults with primary (chickenpox) and secondary varicella zoster virus (VZV) infection.1 Current recommendations by the American Academy of Pediatrics do not include the routine use of oral aciclovir for uncomplicated varicella in otherwise healthy children; individual cases, however, may justify a “modest clinical benefit” from oral aciclovir therapy, provided it can be initiated within the first 24 hours of illness.2 We describe here an otherwise healthy child with chickenpox who developed a unilateral, unifocal choroiditis with overlying serous detachment of the macula. A prompt visual response was observed with oral aciclovir, initiated 5 days after the onset of systemic illness. We suggest, therefore, a role for even delayed systemic antiviral therapy of varicella choroiditis in the immunocompetent patient.
An 11 year old girl presented 5 days after the onset of chickenpox, and 1 day after she developed blurring of vision in the left eye. She denied any pain with eye movements or photophobia.
On examination, the patient had diffuse, non-acute varicelliform lesions of the skin with signs of early crusting. Visual acuity was 20/20 in the right eye, and 20/100 in the left. Pupils were equal in size and reactivity, without afferent defects. The anterior segment examination was unremarkable. Fundus examination of the left eye revealed an irregular, 0.75 disc diameter subretinal lesion with an overlying serous detachment involving the macula (Fig 1). There was no evidence of vitritis. Fluorescein angiography showed early blockage, with late hyperfluorescence and pooling of dye in the subretinal space (Fig 2). Fundus examination of the fellow eye was normal.
The patient was started on oral aciclovir 500 mg four times daily for 1 week, based upon her size and weight. Examination of the involved eye 8 days later revealed visual acuity of 20/40, and regression of her choroidal lesion and sensory detachment. Subtle changes to the retinal pigment epithelium persisted.
Chorioretinal lesions seen in conjunction with primary and secondary systemic VZV infections are relatively rare, with most cases limited to immunocompromised hosts. Barondes et al have, however, described acute retinal necrosis (ARN) in a healthy man 2 weeks after diffuse varicella eruption, where aciclovir and corticosteroids were associated with a favourable outcome.3 Kelly and Rosenthal also describe multifocal choroiditis in an otherwise healthy adult with primary VZV infection, where oral aciclovir resulted in regression of lesions.4
The patient described here is unusual in that the choroiditis was unilateral, unifocal, and involved the macula. Furthermore, there was a significant response to oral aciclovir despite being administered several days after the acute onset of her exanthema.
We therefore suggest that ophthalmologists consider systemic antiviral therapy in immunocompetent children with chickenpox and choroiditis. As this patient’s maculopathy was clinically evident during the convalescent phase of her vesicular lesions, this consideration should still be made independent of the timing of visual symptoms. Furthermore, there was a the acute onset of her exanthema, with a rapid and complete resolution of her symptoms with return of excellent central acuity. Only a small residual pigmentary disturbance of the retinal pigment epithelium persisted. Significant visual changes may occur as a result of this common childhood illness, which may benefit from ophthalmic examination and treatment.
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