Choroidal lesions in varicella zoster virus uveitis

Abstract

Purpose: To evaluate choroidal lesions with spectral domain optical coherence tomography (SD-OCT) scan in varicella zoster virus (VZV) uveitis.

Methods: VZV-uveitis cases which underwent OCT scan for choroidal lesions were studied. SD-OCT scan passing through these lesions was studied in detail. Subfoveal choroidal thickness (SFCT) during active and resolved stages was studied. Angiogaphic features were studied where available.

Results: Thirteen out of 15 cases had same-sided herpes zoster ophthalmicus skin rashes. All except three patients had old or active kerato-uveitis. All eyes demonstrated clear vitreous and a single or multiple hypopigmented orangish-yellow choroidal lesions. The number of lesions remained unchanged during the follow-up on clinical examination. SD-OCT over lesions (n = 11) showed choroidal thinning (n = 5), hyporeflective choroidal elevation during active inflammation (n = 3), transmission effects (n = 4), and ellipsoid zone disruption (n = 7). The mean change in SFCT (n = 9) after resolution of the inflammation was 26.3 μm (range: 3-90 μm). Fundus fluorescein angiography showed iso-fluorescence over lesions in all (n = 5), but indocyanine green angiography (n = 3) showed hypofluorescence at lesions. Mean follow-up was 1.38 years (range: 3 months-7 years). De-novo appearance of choroidal lesion during the first relapse of VZV-uveitis was captured in one case.

Conclusion: VZV-uveitis can cause focal or multifocal hypopigmented choroidal lesions with thickening or scarring of choroidal tissue, depending on the disease activity.

Keywords: Choroidal granuloma; FFA; ICG; OCT; OCTA; VZV; choroidal vitiligo; choroiditis; herpes; hypopigmented choroidal lesion; varicella zoster.

Figure 1

A 61/F, an old case of left HZO came for the routine eye checkup. Fundus examination revealed multiple hypopigmented choroidal lesions in the inferonasal quadrant (a). ICG showed hypofluorescent lesions corresponding to the fundus lesions (b). SD-OCT in the healthy quadrant showed normal choroidal thickness (c), whereas diffuse choroidal thinning was appreciated in the inferonasal quadrant and over the lesions (arrows) (d and e)

Figure 2

A 67/M with a history of HZO presented with kerato-uveitis. Wide field fundus photo shows multiple hypopigmented peripheral choroidal lesions (arrows) (a). SD-OCT scan over the peripheral lesions showed choroidal elevation (b). Decrease in choroidal thickness over the same lesions can be seen after 1 month of treatment with antivirals and topical steroids (c)

Figure 3

Fundus photo of the same patient in Fig. 3 shows choroidal lesions at the macula (a). SD-OCT scan through the temporal lesion shows loss of the ellipsoid zone (vertical arrow) and transmission effect below the lesion (horizontal arrow) (b). SD-OCT scan passing through the inferior lesion to the fovea shows thinning of the choroid (vertical arrow) (c)

Figure 4

Wide-field fundus photo of the left eye at the presentation during the first episode of VZV-kerato-uveitis shows normal fundus (a). Eight months later, during the relapse of kerato-uveitis, the fundus showed multiple hypopigmented choroidal lesions (arrows) (b). SD-OCT scan over the choroidal lesion at the superior macula shows choroidal hyporeflectivity with increased transmission effect (arrow) (c). OCT-angiography (8 × 8 mm scan) of the macula showed normal vasculature of the chorio-capillaries at the site of the choroidal lesion (d)