CaseWise 1 – Viral Endothelitis – A case report

Dr. Shreya Jaiswal, Dr. Prabhat Nangia, Dr. Vinay Nangia
Suraj Eye Institute
559, New Colony, Sadar, Nagpur – 440001

Introduction
Herpes simplex virus (HSV) is endemic throughout the world and humans are the only known natural reservoir. HSV in eye can lead to blepharitis, conjunctivitis, epithelial keratitis, stromal keratitis, endothelial keratitis and viral retinitis. Herpes simplex virus-1 is transmitted primarily through direct contact with infected secretions (i.e., saliva or tears) or lesions.1

Case Report
A female, 59 years of age, reported to us with the chief complaints of pain, redness and blurring of vision in right eye since 15 days. She had no history of trauma, glare or photophobia. She had a history of similar complaint of redness and diminution of vision 3 months and 6 months back, in the same eye, for which she was treated with topical steroids and cycloplegic drops. On examination, she had a best corrected visual acuity (BCVA) of CF 2m in right eye and 6/9 in left eye. Slit lamp biomicroscopy of right eye showed stromal edema, descemet membrane folds, multiple keratic precipitates and grade I cells in anterior chamber and reduced corneal sensation (Fig.1). Left eye was within normal limits. Intraocular pressure was 16mmHg in both eyes. Fundus examination of right eye had hazy media, retina was attached and fovea appeared normal. Left eye fundus examination was within normal limits. 

Figure 1 – Shows base line diffuse(1a) and slit photographs low(b,c) and high magnification (d) of right eye showing stromal edema, descemet membrane folds and keratic precipitates  

Diagnosis and Management:
A provisional diagnosis of right eye viral endothelitis was made and patient was advised –  
E/d Prednisolone 1% 6 times, tapered over 2 months, E/d Carboxymethylcellulose 0.5%, 6 times, E/d Homatropine 2% 2 times, Tab Acyclovir 400 mg, 5 times a day for 2 weeks, to be continued twice daily dosage for 6 months. Patient was reviewed at 1 week, there was significant reduction in corneal stromal edema with a BCVA of 6/18. At 1 month review, the BCVA was 6/12, with complete resolution of edema, keratic precipitates and the patient was asymptomatic (Fig.2). She was advised to taper and stop topical steroids and oral antiviral and to review after 3 months. 

Figure 2 – Diffuse and slit photographs of right eye at 1 month follow up showing clear cornea with no stromal edema, descemet membrane folds and keratic precipitates 

Discussion:
Only a few studies exist to guide treatment recommendations for HSV endothelial keratitis. They compared the combination of topical acyclovir 3% ointment and topical betamethasone2 with acyclovir ointment alone and concluded that the combination regimen produced a faster response with significantly fewer treatment failures. Another study compared topical acyclovir ointment 3% five times daily to oral acyclovir 400 mg five times daily in patients also treated with topical prednisolone 0.05%. The oral acyclovir group demonstrated significantly faster resolution of lacrimation and greater improvement of visual acuity with no difference in the mean healing time.3 A topical corticosteroid agent in conjunction with an oral antiviral agent is the preferred treatment for HSV endothelial keratitis. HEDS trial suggested long term use of oral acyclovir for prophylaxis against recurrent attacks.4 Therefore, we decided to use long term oral acyclovir with topical steroids.

References

  1. White ML, Chodosh J. Herpes simplex virus keratitis: a treatment guideline. Hoskins Centers Compendium of Evidence-Based Eye Care. 2014 Jun. https://pdfs.semanticscholar.org/31e6/52d3851463d67a59e881e1ac8988495e212e.pdf
  2. Power WJ, Hillery MP, Benedict-Smith A, et al. Acyclovir ointment plus topical betamethasone or placebo in first episode disciform keratitis. British journal of ophthalmology. 1992 Dec 1;76(12):711-3. http://dx.doi.org/10.1136/bjo.76.12.711
  3. Porter SM, Patterson A, Kho P. A comparison of local and systemic acyclovir in the management of herpetic disciform keratitis. British journal of ophthalmology. 1990 May 1;74(5):283-5. http://dx.doi.org/10.1136/bjo.74.5.283
  4. Wilhelmus KR, Beck RW, Moke PS, et al. Acyclovir for the prevention of recurrent herpes simplex virus eye disease. New England Journal of Medicine. 1998 Jul 30;339(5):300-6. DOI: 10.1056/NEJM199807303390503

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