Acute onset bilateral myopia in convalescence phase of varicella infection.

A 13 year old boy presented with sudden onset of painless blurring of vision in his both eye, twenty days following varicella infection. Ocular examination revealed -3.00 DS refractive error; and cilio-choroidal effusion. After treatment at 1 months he had unaided 6/6; N-6 vision in both eyes.

Introduction

Acute onset of myopia is an uncommon clinical condition believed to result from an idiosyncratic reaction. We report a case of varicella infection presenting with bilateral acute onset, transient myopia.

Case Report

A 13-year-old boy presented with sudden onset of painless blurring of vision in his both eyes. He had a history of exanthematous fever 20 days back and was treated symptomatically. There were healing skin lesions on face, abdomen and upper and lower limbs [Figure 1a]. On examination, the un-corrected visual acuity in oculi uterque (OU) was 3/60, and best corrected visual acuity was 6/6; N-8 with − 3.00 Diopter spherical (DS) correction. Intraocular pressure (IOP) was 14 and 15 mm Hg, respectively in the right and left eye. Anterior chambers (AC) were quiet and shallow, and on gonioscopy angles were open to anterior trabecular meshwork. By immersion A-scan ultrasonography AC depth (ACD) were 3.47 and 3.41 mm, and lens thickness were 3.64 mm and 3.61 mm, respectively in the right and left eye. Pupils were symmetrical, round, regular and reactive to light. Fundus examination was significant for the presence of bilateral retinal folds in the macular region bilaterally [Figure 1b]. B scan ultrasonography showed features of annular cilliochoroidal effusion [Figure 1c]. A dermatology opinion was taken, which pointed toward varicella, and serum was positive for the specific immunoglobulin M (1.14) antibodies. Patient was started on oral prednisone (50 mg/day) and topical homatropine 2% thrice daily.

Figure 1

(a) 13-year-old boy with varicella lesions over face, abdomen and limbs. (b) Color fundus photograph showing retinal striae (blue arrow) bilaterally. (c) Ultrasound B-scan showing cilio-choroidal effusion (black arrow)

At 1 week follow up unaided distance vision OU had improved to 6/6, and near vision was N-24. The oral prednisolone and homatropine was stopped over 2 weeks. At 4 weeks, unaided vision OU was 20/20; N-6. The AC angle was open to sclera spur on gonioscopy and fundus examination was un-remarkable.

Discussion

Varicella remains primarily a clinical diagnosis owing to the presence of characteristic lesion. The condition, caused by human (alpha) herpesvirus 3 (varicella-zoster virus), usually present with sudden onset of mild fever, constitutional symptoms and generalized itchy skin irruptions which commonly occur in successive crops, with several stages of maturity present at the same time. Ocular manifestations of varicella are diverse and to best of our knowledge and published literature search, this is first case report of acute onset myopia in varicella. There are few case reports of acute onset myopia in systemic lupus erythematous, rheumatoid arthritis, tuberculosis and many more with the use of drugs, mainly topiramate, chlorthalidone and hydrochlorthiazide.[1234] In this case patient received oral paracetamol, which does not have sulphur group, considered responsible in drug-induced myopia in most cases.[5]

The acute onset of myopia results either due to changes in the curvature or refractive index of the lens or anterior shift of iris-lens diaphragm from cilliochoroidal effusion. The suggested pathogenesis of cilliochoroidal effusion is believed to be an idiosyncratic reaction, probably involving prostaglandins.[5] Although exact etiopathogenesis remains unknown in this case, postulated mechanism for the onset of acute myopia is cillio-choroidal effusion, as evident from retinal striae. Definite proof of ciliary body effusion is obtained on ultrasound bimicroscopy.[1] The appositional angle closure in such cases usually also precipitate glaucomatous crisis. Although, in this case, angles were open to anterior trabecular meshwork resulting in normal IOP; cases with normal IOP in presence of closed angle has been reported.[3]

This case highlights an unusual complication of varicella infection and importance of comprehensive clinical examination in backdrop of medical history.