Herpes Zoster Ophthalmicus in Otherwise Healthy Children DENISE DE FREITAS, MD, ELISABETH N. MARTINS, MD, CONSUELO ADAN, MD, LÊNIO S. ALVARENGA, MD, AND DEBORAH PAVAN-LANGSTON, MD ● PURPOSE: To evaluate the complications of herpes zoster ophthalmicus (HZO) in children. ● DESIGN: Prospective-observational case series. ● METHODS: Ten healthy patients (five boys, five girls) with HZO were prospectively followed. Data regarding best-corrected visual acuity, biomicroscopy, intraocular pressure, corneal sensitivity, and funduscopy were col- lected. The median duration of follow-up was 19 months (range eight to 78 months). ● RESULTS: The mean age at presentation was 8.7 years (range two to 14 years 3.95). At last visit, two patients (20%) had decreased visual acuity and nine (90%) had some degree of abnormal corneal sensitivity and corneal opacity despite good final visual acuity. ● CONCLUSION: In general, HZO seems to have a good prognosis in healthy children; nonetheless, some cases can present severe eye complications causing visual loss. (Am J Ophthalmol 2006;142:393–399. © 2006 by Elsevier Inc. All rights reserved.) V ARICELLA ZOSTER (VZV) IS A UBIQUITOUS VIRUS that usually affects school-age children as chicken- pox. The virus lies dormant in the sensorial ganglia and reactivation may occur years later with variable presentations as herpes zoster (HZ). 1 The incidence of HZ increases with age and immunosuppression, and up to 20% of the patients infected by VZV will develop HZ sometime in life. 2 Patients with age-related immunosuppression, malignancy, blood disorders, HIV infection, or on systemic immunosuppressant drugs are particularly prone to this reactivation. 3 The age-adjusted incidence rates of HZ are low in the group 0 to 14 years of age (0.45/1000 person- years) and high among people 75 years and older 4,5 (4.2 to 4.5/1000 person-years). The incidence is lower in the group 0 to 5 years of age (about 20/100 000 person-years) when compared with adolescents (about 60/100,000 per- son-years). 6,7 HZ during childhood is uncommon, 4,8 –17 and reported cases are mostly related to immunosuppression, 18 –20 reactivation of latent VZV infection acquired transplacen- tally, 21 or after varicella during the first year of life. 22 This is attributed to an attenuated immune response of the host to the primary VZV infection. 23 Herpes zoster ophthalmicus (HZO) is the involvement of the ophthalmic branch of the trigeminal nerve by recurrent VZV. It may lead to severe pain and a wide spectrum of sight-threatening complications 2 affecting all ocular and orbital tissues. 24 The sequelae are caused by nerve damage, chronic inflammation, or by direct viral infection. 25 Live VZV is rarely found in the eye, 24 –27 with the exception of corneal dendritic ulcers. 28 In this prospective study, we describe the clinical find- ings and the outcome of healthy, nonvaccinated children with HZO. METHODS PATIENTS NO OLDER THAN 15 YEARS WITH HZO WERE included in the study, from January 1999 to January 2005. The present study was approved by the Ethical Committee of the São Paulo Hospital, Federal University of São Paulo. All patients underwent pediatric evaluation for the detection of any systemic disease that could justify an underlying immunodeficiency, malignancy, malnutri- tion, or HIV infection. The diagnosis was based on the characteristic aspect of the disease: a crop of umbilicated, sometimes hemorrhagic, vesicles and pustules on an erythematous base. We con- sidered lesions that were conspicuously limited to the distribution of the ophthalmic dermatome. Atypical cases were excluded. The distribution of skin lesions was re- corded by anatomic drawings and photography. Ophthal- mologic examination included measurement of best corrected visual acuity, ocular motility test, slit-lamp biomicroscopy, corneal esthesiometry (Cochet-Bonnet es- thesiometer [60 mm = normal reading]), applanation tonometry, and indirect ophthalmoscopy. Evaluations were not always completed at the first visit (e.g., significant Accepted for publication Mar 29, 2006. From the Department of Ophthalmology, Federal University of São Paulo, SP, UNIFESP Rua Botucatu, São Paulo, Brazil (D.D., E.N.M., C.A., L.S.A.); Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, Massachusetts (D.P.-L.). Inquiries to Elisabeth N. Martins, MD, Rua Itapeva 518 cj 1208, CEP 01332-000 São Paulo, SP, Brazil; e-mail: beth@oftalmo.epm.br © 2006 BY ELSEVIER INC.ALL RIGHTS RESERVED. 0002-9394/06/$32.00 393 doi:10.1016/j.ajo.2006.03.059