Open Journal of Ophthalmology, 2012, 2, 83-84
http://dx.doi.org/10.4236/ojoph.2012.23017 Published Online August 2012 (http://www.SciRP.org/journal/ojoph)
83
Post-Varicella Disciform Keratitis: Case Report
Ozlem G. Sahin
The World Eye Center, Department of Uveitis, Ankara, Turkey.
Received March 6th, 2012; revised April 16th, 2012; accepted May 10th, 2012
ABSTRACT
The purpose of this study is to report a rare condition of post-varicella disciform keratitis in a 4-year-old child. It is a
prospective study of the follow-up of a 4-year-old girl who was diagnosed as post-varicella stromal disciform keratitis
related to high serum antibody titers five months after the skin lesions. Rapid response to topical steroids, topical and
oral antivirals have been observed in 6 weeks of treatment. There was no recurrence in the 6 months of follow-up. Total
resolution of the disciform stromal keratitis in a short period of time was disclosed with an effective treatment of both
topical and oral antivirals and topical steroids.
Keywords: Acyclovir; Disciform Keratitis; Trifluridine; Varicella Zoster
1. Introduction
Although varicella infections are common in Turkey
related to the low varicella vaccination coverage, systemic
and ocular complications are rare [1]. Corneal complications
of varicella zoster virus include epithelial, stromal and
disciform keratitis [2]. These complications are usually
sight threatening, and they might lead to substantial visual
disability [2]. We report a rare condition of post-varicella
disciform keratitis in a 4-year-old child.
2. Case Report
A 4-year-old white female having a history of skin rash/
vesicles 5 months ago presented with a haze on her right
eye. Best corrected visual acuity (BCVA) of her right eye
was 20/100, and her left eye was 20/20 (Snellen chart).
The extraocular muscle functions and the pupillary light
reactions were normal in both eyes. Her right cornea
revealed a central localized area of disciform stromal
edema without keratic precipitates (Figure 1). There was
no cell and flare in the right anterior chamber. The right
iris and pupil were normal, and the lens was clear. The slit-
lamp examination of the left eye revealed no abnormalities.
The fundus examinations of both eyes were normal. The
intraocular pressure of the right eye was 18 and the left
eye was 15 mmHg. Her specific serum IgM antibody
against the varicellla zoster virus (VZV) was 1.04 ( <0.9
negative, >1.1 positive), and her specific serum IgG anti-
body against VZV was 2.94 (<0.6 negative, >0.9 posi-
tive). The culture and antibody titers to the other viruses
including herpes simplex, rubella, ebstein barr and cyto-
megalovirus were negative. She was diagnosed as post-
varicella right disciform stromal keratitis. She was
treated with frequent instillation of prednisolone acetate
and trifluridine four times a day associated with oral
acyclovir 20 mg/kg four times a day for 14 days. Her
right cornea disclosed reduction of disciform stromal edema
at the 2nd week of treatment (Figure 2). Prednisolone
acetate was tapered and trifluridine were discontinued.
Her treatment with slow reduction of prednisolone ace-
tate was continued for 4 more weeks. The BCVA in the
right eye improved to 20/20 at the 6th week of therapy,
and her right cornea was clear without scarring, neo-
vascularization, or lipid deposition (Figure 3). She is
currently on the follow-up for possible recurrences, but
no recurrence of keratitis was noted in the 6 months of
follow-up.
Figure 1. Color photo of the right eye at presentation. Note
the central localized area of disciform stromal edema with-
out keratic precipitates.

Post-Varicella Disciform Keratitis: Case Report
84
Figure 2. Color photo of the right eye at the 2nd week of
treatment. Note the reduction of disciform stromal edema.
Figure 3. Color photo of the right eye at the 6th week of
treatment. Note the clear cornea without scarring, neovas-
cularization,or lipid deposition.
3. Discussion
VZV is a rare cause of disciform stromal keratitis that
may occur and recur several weeks or months after the
primary skin rash has resolved [3,4]. Delayed onset of
keratitis represents a distinct category of VZV corneal
complications [5]. Previouly it was reported in 5 cases
aged 4 - 26 years old within 1 - 10 weeks after onset of
acute vesicular exanthem [3]. Our case was a 4-year-old
female having a history of preceding skin eruption 5
months ago. Serologic analysis was reported helpful for
the diagnosis of post-varicella keratitis [5]. Negative
cultures, positive antibodies against VZV and negative
antibodies against herpes simplex virus were important
factors for serological diagnosis [5]. Our case revealed a
positive serum specific IgG with a negative serum specific
IgM titers for VZV indicating a delayed onset of VZV
keratitis.
Antiviral therapy was considered an important inter-
vention in clinical practice [6]. Oral acyclovir was as an
effective and useful drug of choice for the management of
varicella in healthy children and adolescents [6]. The use
of topical steroids alone might be harmful initially, and
might increase the recurrence rate in the follow-up [7].
Trifluridine 1% solution was also effective for treating
herpetic keratitis and seemed especially useful in difficult
cases [8]. Our case showed a rapid resolution of the
disciform stromal keratitis with frequent instillation of
topical steroids and antivirals, and oral acyclovir. Based
on this case and on a review of the literature, we believe
that this delayed onset of keratitis represents a rare
category of varicella corneal complications. However, it
has a rapid and complete resolution with an effective
treatment. We recommend oral acyclovir in conjunction
with topical 1% trifluridine drops, and steroids for the
therapy of post-varicella disciform keratitis.
REFERENCES
[1] Z. Kurugol, O. Halicioglu, F. Koc, G. Koturoglu and S.
Aksit, “Varicella Rates among Unvaccinated and One-
Dose Vaccinated Healthy Children in İzmir, Turkey,”
International Journal of Infectious Diseases, Vol. 15, No.
7, 2011, pp. 475-480. doi:10.1016/j.ijid.2011.03.016
[2] S. Sanjay, P. Huang and R. Lavanya, “Herpes Zoster
Ophthalmicus”, Current Treatment Options in Neurology,
Vol. 13, No. 1, 2011, pp. 79-91.
doi:10.1007/s11940-010-0098-1
[3] K. R. Willhelmus, M. B. Hamill and D. B. Jones, “Vari-
cella Disciform Stromal Keratitis,” American Journal of
Ophthalmology, Vol. 111, No. 5, 1991 pp. 575-580.
[4] J. Martinez, F. Laqoutte and L. Gauthier, “Post-Varicella
Disciform Keratitis,” Journal Français D’Ophtalmologie,
Vol. 15, No. 11, 1991, pp. 597-600.
[5] D. de Freitas, E. H. Sato, L. D. Kelly and D. Pavan-Lang-
ston, “Delayed Onset of Varicella Keratitis,” Cornea, Vol.
11, No. 5, 1991, pp. 471-474.
doi:10.1097/00003226-199209000-00018
[6] A. M. Arvin, “Antiviral Therapy for Varicella and Herpes
Zoster,” Seminars in Pediatric Infectious Diseases, Vol.
13, No. 1, 2002, pp. 12-21. doi:10.1053/spid.2002.29753
[7] J. McGill, “The Enigma of Herpes Stromal Disease,” Bri-
tish Journal of Ophthalmology, Vol. 71, No. 2, 1987, pp.
118-125. doi:10.1136/bjo.71.2.118
[8] A. A. Carmine, R. N. Brogden, R. C. Heel, T. M. Speight
and G. S. Avery, “Trifluridine: A Review of Its Antiviral
Activity and Therapeutic Use in the Topical Treatment of
Viral Eye İnfection,” Drugs, Vol. 23, No. 5, 1982, pp.
329-353. doi:10.2165/00003495-198223050-00001