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CASE STUDY

45-year-old woman with increasing blurred vision and photophobia

Dr Nima Pakrou

18/07/2018

History/Presentation

A 45-year-old female was referred for increasing blurred vision and photophobia in her right eye over the preceding week, with reduced foreign-body sensation. She had previously been referred to an ophthalmologist with similar symptoms.

RVA: 6/7.5
LVA: 6/5

Figure 1: Slit lamp image of right eye showing small subepithelial infiltrates.

 

 

Figure 2: Fluorescein stain (right eye) confirms the presence of small epithelial defects

The patient reveals a history of cold sores, including a recent flare-up. Approximately 12 months ago, she had seen another ophthalmologist for the same symptoms and the patient notes confirmed she had been treated with Maxidex and Zovirax.

Diagnosis

Given her history and presence of small epithelial defects (but not dendrites), it is highly likely this patient has herpes simplex virus (HSV) keratouveitis.

Treatment

Oral famciclovir was discussed with the patient as an alternative anti-viral option. Compared to topical Zovirax, oral famciclovir offers quicker resolution of symptoms, less corneal toxicity and some added benefit if uveitis is present. However, the cost is often prohibitive for patients because it is not listed on the PBS for HSV.

Progress

2 weeks after presentation

Figure 3: Slit lamp examination of right eye 2 weeks after beginning treatment. No epithelial defects evident.

4 weeks after presentation

Figure 4: Slit lamp examination of right eye 4 weeks after initial presentation.

Figure 5: Fluorescein stain confirms the recurrence of small right epithelial defects. The patient admitted to stopping treatment after 3 weeks.

 

Managing HSV recurrence

The patient was asked to return for a review in 1–2 weeks and again 2 weeks after stopping treatment (or ASAP if symptoms are worsening).

HSV keratitis nomenclature

  1. Epithelium
    • HSV epithelial keratitis (dendritic epithelial ulcer or geographic epithelial ulcer)
  2. Stroma
    • HSV stromal keratitis without ulceration (non-necrotising keratitis, interstitial keratitis, immune stromal keratitis)
    • HSV stromal keratitis with ulceration (necrotising keratitis)
  3. Endothelium
    • HSV endothelial keratitis (disciform keratitis)

 

DENDRITIC ULCER

dendritic-ulcer-nima dendritic-ulcer-nima-2

 

HERPETIC KERATOUVEITIS

herpetic-keratouveitis-nima

 

RECURRENT INTERSTITIAL KERATITIS + NEW DISCIFORM

recurrent-interstitial-keratitis_nima

 

ENDOTHELIAL/DISCIFORM KERATITIS

endothelial-keratitis_nima

Figure 6: Area of localised corneal oedema and a few keratic precipitates, consistent with a diagnosis of disciform keratitis. AC inflammation if minimal. If there is moderate AC inflammation (AC cells >1+), then a diagnosis of keratouveitis is likely.

endothelial-keratitis_nima-3

 

HERPETIC SCARS

herpetic-scars 1herpetic-scars 2

 

GEOGRAPHIC ATROPHY

geographic-atrophy

 

HSV keratitis treatment protocol

Epithelial disease only

Topical corticosteroids should be avoided in the initial management of HSV epithelial keratitis.

  1. Dendritic ulcer
    • Debride/debulk: LA-soaked cotton wool rolled over lesion
    • Topical acyclovir: 5 times per day day 7/7, tds 7/7 OR
    • Oral aciclovir, valaciclovir, famciclovir: 7–10 days then lower dose
  2. Geographic ulcer
    • Topical aciclovir: 5 times per day until healing then tds 7/7
      • Watch for toxicity/non healing/worsening, which requires oral Rx
      • Intensive gel lubricants (e.g. Genteal Tears)
    • Oral antivirals (maximum dose): 2–3/52 (preferred as less corneal toxicity) but are expensive 

Stromal disease

  1. Without epithelial ulceration
    • Topical steroids: 4–6 times per day, tapering quickly at first and then more slowly (e.g. by 1 drop weekly for first 3­–4 weeks then every second week for next 4–6 weeks)
    • May need 6–12 weeks of treatment, depending on response and history
    • Oral/topical antiviral cover: lower/prophylactic oral dose of acyclovir or famciclovir or bd–tds topical Zovirax cover
  2. With epithelial ulceration
    • Antiviral cover: topical or oral using therapeutic (higher) dose
    • Topical steroids: lower dose (e.g. bd) until ulcer heals then increase as necessary OR
    • Withhold steroid for first 24–36 hours of antiviral therapy before commencing lower dose and increasing once ulcer heals
    • Taper steroids as above or based on disease response

Endothelial keratitis/disciform keratitis

If AC inflammation is severe, steroids may need to be administered more frequently.

HSV long-term oral prophylaxis

Prophylaxis is considered in patients with:

Key message:

Herpes viruses, including HSV1, HSV2 and VSV, can all affect the eye. The possible diagnosis of such conditions should always be kept in the back of the mind in any patient presenting with corneal inflammatory changes (oedema, infiltrates, epithelial defect) and/or uveitis. Any patient with suspected corneal herpetic disease must have a dilated exam to look for intraocular involvement.

 

Dr Nima Pakrou is an experienced ophthalmologist with expertise across a range of eye conditions. His subspecialty areas include medical retinal diseases, cataracts, intraocular inflammation and oculoplastics. He practises at Vision Eye Institute Footscray.

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