4
VARICELLA AND THE CORNEA 53 REFERENCES |*ur Nedden. Ueber Keratitis superficialis punctata. Klin. M. f. Augenh., 1939, v. 102, p. 487. Schneider, R. Kurzer Bericht iiber eine Erkranknng des vorderen Bulbusabschnittes nn- t bekannter Ursache. Klin. M. f. Augenh., 1939, v. 102, p. 130. Holmes, W. J. Epidemic infectious conjunctivitis. Hawaii Med. Jour., 1941, v. 1, Nov., p. 11. VARICELLA AND THE CORNEA* A CASE REPORT H. D. ROSENBAUM, MAJOR (MC), A.U.S. Fort Leavenworth, Kansas It is indeed unusual for a condition as commonly known as chicken pox to have so few ocular lesions associated with it; at least the reports in the literature and textbooks are relatively meager. An at- tempted explanation for this will be given later in this paper. However, the eye dis- orders reported as complicating varicella range from bilateral papilledema associ- ated with encephalitis (Mayerhofer and Creitenfeld 1 ) to ophthalmoplegia extrin- sica (Marfan 2 ). One of the most common lesions seen with this acute exanthema is a phlyctenu- lar, or vesicular type of conjunctivitis. Such a case has been noted by Hilbert, 2 who described inflammatory changes in the bulbar conjunctiva of a six-month-old infant affected with varicella. Trantas 2 reported a case of mild con- junctivitis with chicken pox, associated with a bilateral superficial keratitis. Roger 2 observed a mild case of con- junctivital eruption. Lowenstein 3 long ago reported a con- dition of the iris which he called "vitiligo iridis," seen following herpetic infec- tions. He mentioned this depigmentation as following inflammatory changes and hemorrhages occurring with herpes zoster and smallpox; he was also able to induce * From the Eye, Ear, Nose, and Throat Service, Station Hospital. this depigmentation in rabbits by inocu- lating the virus of herpes febriles into the anterior chamber. Knowing the close bio- logic relationship of the viruses and chicken pox, he expected a similar picture in varicella. This was found and reported as a case in which there was also a cor- neal opacity. Accardi, 2 who reviewed the literature thoroughly, concluded that lesions of the iris seen with variola, as reported by Miiller, Lowenstein, Carmi, and Alajmo, were also sometimes evident with vari- cella. His case was that of an eight-year- old girl who had had chickenpox and ex- hibited in the iris stroma, round spots, pearly in color, and devoid of pigment. However, he preferred the name "post- varicellar" leucoridia to that given by Lowenstein. Chow 4 reported two cases of chicken pox of the cornea, but both were in rela- tion to a conjunctivitis; these took the form of phlyctenularlike lesions at the limbus and seemed to heal rapidly, leaving no permanent damage. In contrast to cor- neal lesions seen with smallpox, in which the prognosis is very unfavorable, the lesions of chicken pox usually heal with- out scar formation. Pickard 0 mentioned the rarity of cor- neal affections in varicella and reported a case in a 10-year-old boy. There were evi- dently no conjunctival lesions present,

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Page 1: Varicella and the Cornea*

VARICELLA AND THE CORNEA 53

REFERENCES

|*ur Nedden. Ueber Keratitis superficialis punctata. Klin. M. f. Augenh., 1939, v. 102, p. 487. Schneider, R. Kurzer Bericht iiber eine Erkranknng des vorderen Bulbusabschnittes nn-

t bekannter Ursache. Klin. M. f. Augenh., 1939, v. 102, p. 130. Holmes, W. J. Epidemic infectious conjunctivitis. Hawaii Med. Jour., 1941, v. 1, Nov., p. 11.

VARICELLA AND THE CORNEA*

A CASE REPORT

H. D. ROSENBAUM, MAJOR (MC), A.U.S. Fort Leavenworth, Kansas

It is indeed unusual for a condition as commonly known as chicken pox to have so few ocular lesions associated with it; at least the reports in the literature and textbooks are relatively meager. An at-tempted explanation for this will be given later in this paper. However, the eye dis-orders reported as complicating varicella range from bilateral papilledema associ-ated with encephalitis (Mayerhofer and Creitenfeld1) to ophthalmoplegia extrin-sica (Marfan2).

One of the most common lesions seen with this acute exanthema is a phlyctenu-lar, or vesicular type of conjunctivitis. Such a case has been noted by Hilbert,2

who described inflammatory changes in the bulbar conjunctiva of a six-month-old infant affected with varicella.

Trantas2 reported a case of mild con-junctivitis with chicken pox, associated with a bilateral superficial keratitis.

Roger2 observed a mild case of con-junctivital eruption.

Lowenstein3 long ago reported a con-dition of the iris which he called "vitiligo iridis," seen following herpetic infec-tions. He mentioned this depigmentation as following inflammatory changes and hemorrhages occurring with herpes zoster and smallpox; he was also able to induce

* From the Eye, Ear, Nose, and Throat Service, Station Hospital.

this depigmentation in rabbits by inocu-lating the virus of herpes febriles into the anterior chamber. Knowing the close bio-logic relationship of the viruses and chicken pox, he expected a similar picture in varicella. This was found and reported as a case in which there was also a cor-neal opacity.

Accardi,2 who reviewed the literature thoroughly, concluded that lesions of the iris seen with variola, as reported by Miiller, Lowenstein, Carmi, and Alajmo, were also sometimes evident with vari-cella. His case was that of an eight-year-old girl who had had chickenpox and ex-hibited in the iris stroma, round spots, pearly in color, and devoid of pigment. However, he preferred the name "post-varicellar" leucoridia to that given by Lowenstein.

Chow4 reported two cases of chicken pox of the cornea, but both were in rela-tion to a conjunctivitis; these took the form of phlyctenularlike lesions at the limbus and seemed to heal rapidly, leaving no permanent damage. In contrast to cor-neal lesions seen with smallpox, in which the prognosis is very unfavorable, the lesions of chicken pox usually heal with-out scar formation.

Pickard0 mentioned the rarity of cor-neal affections in varicella and reported a case in a 10-year-old boy. There were evi-dently no conjunctival lesions present,

Page 2: Varicella and the Cornea*

54 H. I). ROSENBAUM

though the membrane was slightly pink. The cornea presented a picture involving its entire thickness, with swelling of the posterior portions; there was also a brown exudate on the endothelial surface con-fined to the site of the inflamed cornea. However, despite the relatively marked

Fig. 1 (Roscnbaum). Sketcli showing infiltra-tion on anterior surface of cornea (A), and on the posterior surface (B).

infiltration, the eye healed completely and retained normal vision.

Oppenheimer's0 case, which was one of the first to be reported, differed from the preceding one in that it started as a sim-ple corneal bleb which ruptured and left a superficial ulcer. This healed promptly and left no visible defect.

However, Post7 had a case which left a marked corneal scar with much impair-ment of vision.

There was no mention made in any of the aforementioned reports of the pres-ence of either "Paul's excrescences" or "Guarnieri bodies."8 It is possible that

inoculation of the rabbit's cornea with the varicella virus would produce intracellu-lar inclusions similar to those found after vaccinia or herpes-virus injection.

Case report: Captain H. K. W., a stu-dent at the Command and General Staff School, Fort Leavenworth, Kansas, was first seen in the Eye Clinic on January 24, 1942 His chief complaint was "dimness of vision" of the right eye for two days, and some redness of the right eye. His history was as follows: On January 6, 1942, he began having aching pains in his back, arms, and legs, together with a feeling of general malaise. These symp-toms, in view of the prevalence of upper-respiratory infections at that time, made the patient feel as though he had the "flu." Two small pimples on the skin over the right collar bone were noted by the patient, but little attention was paid to them. He continued with his work despite the continuance of the general aching and malaise and the feeling of some fever at night. On January 9th, there was a slight breaking out on his face, which looked to him like "hives"; he reported to the Out-Patient Clinic where a diagnosis of chicken pox was made. From January 6th to 16th, the symptoms of general discom-fort continued, and he was literally cov-ered with typical varicellar lesions from head to hips; the scalp was markedly af-fected. There was a particularly heavy group of vesicles just over the right check, and a few on the right eyebrow. He had no trouble with his eyes, except for an occasional sharp pain in his right eye. The pain appeared and disappeared with extreme suddenness. No redness not-tearing was evident at that time.

The lesions persisted for about seven days, then a gradual process of resorption started. On January 22d, while washing his face, he felt a sudden sharp pain in the right eye; there was considerable tearing and photophobia, and the discom-

Page 3: Varicella and the Cornea*

VARICELLA AND THE CORNEA 55

fort lasted approximately three hours. Following this, there was a constant feel-ing of irritation, as though a "foreign body were in the eye"; there was no ex-cessive tearing, and only a mild redness. However the vision in the right eye was noticeably blurred and caused the patient to consult the ophthalmologist.

Previous eye history and past general history were entirely negative.

Examination: Vision, right eye was 2 0 / 4 0 - 3 ; left eye, 20/20. The lids and lacrimal apparatus were entirely normal; the external ocular movements full in all directions. Ocular tension of both eyes was normal to finger palpation. The pupil of the right eye measured approximately 3 mm. in diameter, of the left about 4 mm.—both reacted promptly to light and accommodation. The conjunctivas were clear, and no lesions nor scars were seen. There was a mild redness of the palpebral portion of the upper and lower lids, and a very slight amount of pericorneal injec-tion of the right eye. Situated in almost the exact center of the cornea of the right eye was a small, perfectly rounded stip-pled haziness, measuring about 1.5 mm. in diameter. When examined with the slitlamp, a small, shallow, excavated area was seen, surrounded by a ring of slight infiltration and edema. The borders of the denuded area were very slightly raised, and overhanging the edges were what appeared to be epithelial filaments, such as are evident after the rupture of a vesicle. The ulcerated area stained very faintly with 2-percent fluorescein. The surrounding infiltration extended only a slight distance into the corneal depth ; however, on the posterior surface, there were visible some infiltrations into Desce-met's membrane and into the endothe-Hum. The corneal tissue between these infiltrations appeared perfectly normal. In the aqueous humor no free cells were seen, nor any dilatation of vessels on the

anterior surface of the iris. There was some degree of anesthesia of the cornea of the right eye as compared to that in the essentially normal left eye.

On the right cheek, just below the in-ferior orbital margin, were three rounded, reddened, slightly umbilicated scars; there was a similar scar in the right brow.

The treatment outlined was the use of 1-percent ethyl morphine hydrochloride three times each day, followed by hot, wet compresses for 20 minutes. There was a steady resorption of the infiltration and edema, and by February 5th the vision of the right eye was 20/30, and only a faint grayish area remained. The infiltration on the posterior surface disappeared com-pletely within 10 days, and that anteriorly was also rapidly disappearing when the officer was transferred from this School, on about February 11, 1942. However, Dr. E. P. Norwood of Corsicana, Texas, was kind enough to send me a report of his examination on March 2, 1942. Vision had improved to 20/20—2, and only a faint leucoma was visible over the pupil-lary area. The pupils were equal and re-acted promptly to light and accommoda-tion.

The history of this case in addition to the typical herpetic appearance, without any demonstrable conjunctival defect, warranted the diagnosis of corneal lesion associated with chicken pox. From the appearance alone it could very well have been a herpes of the cornea, and, since the location of the skin lesions was decid-edly pronounced in the areas of distribu-sion of the 1st and 2d divisions of the fifth nerve, some herpetic relationship was undoubtedly present. This has been men-tioned by LSwenstein and Pickard, as well as others.

The relatively minor symptoms to-gether with the resultant mild ocular dis-turbance might account for the supposed "infrequency" of primary varicellar cor-

Page 4: Varicella and the Cornea*

56 H. D. ROSENBAUM

neal lesions. Since most chicken pox is in children and their power of observation is less than that in adults, it is easily possible that many cases of this type can heal in the absence of ocular examination, either by the ophthalmologist or the pediatrician.

The case reported here is almost identi-cal with that of Oppenheimer ;fi it also closely resembles the condition in Pick-

ard's6 patients. In all three of these, the lesion presented itself late in the disease, occurring on the sixth day in Oppen-heimer's, on the twenty-first day in Pick-ard's, and on the sixteenth day in this case; the lesions were relatively small and well circumscribed, caused little or no iridic reaction, and all healed rapidly and completely.

REFERENCES

'Mayerhofer and Breitenfeld. Arch. f. Kinderh., 1933, v. 10, pp. 155-167. 'Cases of Marfan, Hilbert, Trantas and Roger taken from Accardi's review. Bull. d'Ocul.,

Firenze, 1931, v. 10, p. 958. 1 Lowenstein, A. Brit. Jour. Ophth., 1940, v. 94, p. 391-398. ' Chow, Yan. Klin. M. f. Augenh., Stuttg., 1925, v. 75, pp. 484-488. 1 Pickard. Brit. Jour. Ophth., 1936, v. 20, pp. 15-18. ' Oppenheimer. Deutsche Med. Woch., 1905, v. 31, p. 833. ' Post, L. T. Personal communication. 'Levadite and Schoen. Compt. rend. Soc. de Biol., v. 119. From Duke-Elder, Sir W, S., Text-

book of ophthalmology. St. Louis, Mo., C. V. Mosby Co., 1907, v. 2, p. 1907.