Spark ImageWise 14 – Cornea

Corneal Epithelial Dendrite

Dr. Prabhat Nangia, Dr. Sarang Lambat, Dr.  Vinay Nangia
559, Suraj Eye Institute, Nagpur.

Case Description
A female, 58 years of age, came for follow up after 2 years. She complained of mild pain, further diminution of vision and foreign body sensation since 5 days. She was a known case of glaucoma, with past history of penetrating keratoplasty and phacoemulsification in right eye, and old retinal vein occlusion post intravitreal injections in left eye. On examination, best corrected visual acuity was 6/60, N36 in right eye and 6/24, N10 in left eye.

Figure 1: Anterior segment evaluation of right eye showed a failed corneal graft with paracentral epithelial irregularity (Fig. 1A, yellow arrows), which on fluorescein staining revealed a 6 mm long by 2 mm wide epithelial dendrite (Fig. 1B, yellow arrows) with terminal end bulbs (Fig. 1B, white arrows). Application of rose bengal stained the edges of the dendrite (Fig. 1C, yellow arrows) but not the base which was stained by fluorescein. There was an immature senile cataract in left eye. 
Figure 3: Anterior segment examination of right eye on fluorescein staining of cornea shows stained epithelial irregularities in a linear pattern (pink arrow).
Figure 4: Anterior segment examination of left eye on fluorescein staining of cornea shows loose elevated epithelium showing negative staining (pink arrow) with punctate erosions (Micro erosions) (yellow arrow). 

Based on the clinical features, a diagnosis of herpes simplex epithelial keratitis in a failed graft was made and treatment was initiated with acyclovir 0.3% ointment 5 times a day along with carboxymethylcellulose 0.5% eye drops 6 times a day in right eye, for two weeks.

Figure 2: The dendrite resolved within 5 days with presence of epithelial bullae in the same area (Fig. 2A, yellow arrows), which was confirmed with fluorescein staining (Fig. 2B, yellow arrows). 

Discussion

Herpes simplex epithelial keratitis can occur during primary infection with the virus in childhood or during reactivation in older age. It may present as a viral dendrite with terminal end bulbs as in our patient, or a geographic ulcer which may form in patients where the dendrites coalesce if untreated, leading to a larger epithelial defect. The base of the dendrite stains with fluorescein, while the edges and terminal bulbs stain with rose bengal. This typical clinical picture allows us to make a diagnosis without the need for culture and PCR. 

Spontaneous recovery in epithelial keratitis may occur in upto 50% patients. However, treatment should be initiated to decrease discomfort, prevent complications and hasten recovery. These eyes may be treated with oral (acyclovir, valacyclovir) or topical (acyclovir, ganciclovir) antiviral agents. Additionally, epithelial debridement may help reduce the viral load. In recurrent cases, the use of human amniotic membrane has been described for epithelial healing and for its potential antiviral effect. In our patient, we observed fairly rapid resolution of the dendrite within a short period of time with topical antiviral therapy. 

It is important to note that herpetic keratitis is a recurrent disease, and the patients should be reviewed every 6 months or as and when required. Additionally, treatment with topical acyclovir should not be continued beyond three weeks, due to the possibility of toxic keratopathy. 

ReadWise

  1. Roozbahani M, Hammersmith KM. Management of herpes simplex virus epithelial keratitis. Curr Opin Ophthalmol. 2018 Jul;29(4):360-364 doi: 10.1097/ICU.0000000000000483
  1. Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2015 Jan 9;1:CD002898 https://doi.org/10.1002/14651858.CD002898

Correspondence 

Dr Prabhat Nangia
DNB, FICO, FMRF, FAICO
Consultant  
Department of Cornea and Ocular Surface
Suraj eye Institute
Email – education@surajeye.org

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