The authors conducted this retrospective case series to describe the clinical characteristics, treatment and outcomes of herpes simplex virus (HSV) infections of the cornea and adnexae in children, and to raise awareness and improve management of this eye disease in this population. They found a high rate of misdiagnosis, stromal involvement, recurrence and vision loss.
Most of the children (46/53) in the study received oral acyclovir for treatment or prophylaxis, with good tolerance overall. The authors found that oral acyclovir was effective and long-term use was not associated with significant safety issues. However, the dosage must be adjusted as the child grows.
The study reports outcomes for 53 pediatric patients (57 eyes) with herpes simplex keratitis (HSK), herpes simplex blepharoconjunctivitis (HBC) or both in an academic cornea practice. They believe this is the largest cohort of pediatric patients with HSV infection of the cornea and external eye. The patients ranged up to 16 years in age. The median age at onset was 5 years. Mean follow-up was 3.6 years.
Eighteen eyes had HBC only; four patients in this group had bilateral disease. Of 39 eyes with keratitis, 74 percent had stromal disease. Thirty percent of HSK cases were misdiagnosed before presentation, some for a number of years before referral. Seventy-nine percent of patients with keratitis had corneal scarring, and 26 percent had vision of 20/40 or worse at the last visit. Eighty percent of patients had recurrent disease.
Six of 16 patients (37 percent) receiving long-term oral acyclovir had recurrent HSV, at least one case of which followed a growth spurt that caused the baseline dosage of acyclovir to become subtherapeutic.
The authors note that all of the bilateral cases manifested HBC alone, and there were no cases of bilateral corneal involvement. The bilateral cases occurred in children with a history of asthma, trauma, or systemic disease, findings consistent with previous reports demonstrating that bilateral herpetic disease tends to occur in younger patients with atopy and in patients with an altered immune system.
Blepharitis-associated peripheral keratitis and corneal neovascularization was occasionally mistaken as staphylococcal blepharokeratoconjunctivitis or phlyctenular keratoconjunctivitis. The authors recommend careful examination and a thorough history in order to help to distinguish these conditions from HSV.
More than one quarter of children with corneal HSV infection (11/39) showed astigmatism of more than 2 diopters. The authors say correction of refractive error and amblyopia management in conjunction with a pediatric ophthalmologist are essential to reduce the visual burden of HSV infection in children.