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Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 58-60

Herpes simplex viral keratitis - A mixed bag of challenging case scenarios

Department of Cornea, Dr. Shroff's Charity Eye Hospital, New Delhi, India

Date of Submission15-Aug-2022
Date of Acceptance18-Nov-2022
Date of Web Publication20-Jan-2023

Correspondence Address:
Manisha Acharya
Head, Cornea and Anterior Segment Services, Dr. Shroff's Charity Eye Hospital, 5027 Kedarnath Road, Daryaganj, New Delhi - 110 002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1974_22

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Herpes simplex virus (HSV) keratitis is a potentially blinding condition of the eyes. HSV can afflict any of the anatomical layers of the cornea, sometimes more than one layer at one time, and presents with a spectrum of clinical manifestations. Recalcitrant course, recurrences, and variable response to therapy can make managing these patients a true challenge, particularly in the pediatric age group and recipients of corneal transplants. Here, we report a series of five cases of HSV keratitis from our practice that presented with diagnostic and management dilemmas and were successfully managed with a combination of medical and surgical treatment.

Keywords: Herpes simplex virus, keratitis, keratoplasty, neurotrophic keratitis

How to cite this article:
Singh A, Acharya M. Herpes simplex viral keratitis - A mixed bag of challenging case scenarios. Indian J Ophthalmol Case Rep 2023;3:58-60

How to cite this URL:
Singh A, Acharya M. Herpes simplex viral keratitis - A mixed bag of challenging case scenarios. Indian J Ophthalmol Case Rep [serial online] 2023 [cited 2023 Feb 1];3:58-60. Available from: https://www.ijoreports.in/text.asp?2023/3/1/58/368197

Herpes simplex virus (HSV) disease is endemic throughout the world.[1] The virus remains latent in sensory and autonomic ganglia and approximately 40% of patients experience two to five relapses in a lifetime.[2] In developing countries, it is reported to affect the younger population more than in the west.[3] Bilateral disease is reported to be less common but more severe than unilateral disease.[4] Herpetic eye disease study (HEDS) guidelines, which recommend the use of oral antiviral drugs and topical steroids, are most widely used in clinical practice in managing HSV epithelial and stromal keratitis patients worldwide today. However, at times, available diagnostic and therapeutic options do not provide certain solutions. Simple techniques such as Giemsa staining for diagnosis and recording corneal sensations for diagnosis and monitoring disease progression can be helpful. The purpose of this case series is to report five challenging case scenarios of HSV keratitis and their complex management comprising of medical and surgical techniques from our practice.

  Case Reports Top

Case 1

A 13-year-old boy presented with epithelial bullae and central disciform stromal edema (5 × 6 mm) [Figure 1]a. The best corrected visual acuity (BCVA) in the left eye was counting fingers (CF). The polymerase chain reaction (PCR) test for HSV was negative. A diagnosis of immune-mediated stromal HSV keratitis was made. The lesion resolved on prescribing oral acyclovir 400 mg two times a day, prednisolone acetate (1%) eyedrops in tapering doses, and cycloplegic eyedrops over 6 weeks [Figure 1]b. The patient presented 6 months later with epithelial dendrites on the discontinuation of prophylactic oral acyclovir (400 mg twice a day).
Figure 1: Slit-lamp examination of the cornea of a 13-year-old boy who presented with (a) epithelial bullae and central disciform stromal edema suggestive of immune-mediated stromal HSV keratitis. (b) Healed cornea in the same patient on antiviral and steroid therapy at 6 weeks. (c) Clinical image depicting deep stromal infiltration and thinning under a near total corneal epithelial defect in a 45-year-old male patient. (d) Amniotic membrane transplantation (AMT) with tarsorrhaphy was performed. (e) Resolution of infection with stromal scarring over 7 weeks of treatment

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Case 2

A 45-year-old male patient presented with an 8 × 8 mm epithelium defect and deep stromal infiltration [Figure 1]c in the right eye. BCVA in the right eye was CF. Smear examination showed multinucleated giant cells on Giemsa staining suggestive of HSV infection. The patient was prescribed oral acyclovir (400 mg five times a day) along with topical steroid eye drops. Amniotic membrane transplantation (AMT) with tarsorrhaphy was performed on the day of presentation [Figure 1]d. The lesion healed with corneal scarring over a period of 7 weeks [Figure 1]e.

Case 3

A 33-year-old male patient, a known case of recurrent bilateral HSV, presented with 3 × 3 mm epithelium defect, mid-stromal infiltration, corneal thinning, and vascularization in the right eye. BCVA in the right eye was the ability to perceive hand movements (HM). He had undergone keratoplasty in the left eye for HSV keratitis 2 years ago and had subsequently developed absolute glaucoma. The ulcer healed over 2 weeks with oral acyclovir (400 mg five times a day); however, 1 month later, the patient presented with corneal perforation in the left eye [Figure 2]a. Cyanoacrylate glue was applied and lateral tarsorrhaphy was performed [Figure 2]b. Six weeks after healing, the patient presented with a 3 × 4 mm geographical ulcer as a third episode of recurrence [Figure 2]c.
Figure 2: Clinical image of a one-eyed 33-year-old male patient depicting (a) corneal perforation after a recently healed episode of HSV keratitis. (b) Cyanoacrylate glue was applied and lateral tarsorrhaphy was performed. (c) The patient presented again 6 weeks later with a geographical ulcer. (d) A 66-year-old patient with recurrent HSV keratitis presented with stromal infiltration and corneal melting (white arrows). (e) The ulcer healed over 6 weeks on antivirals and topical steroids. (f) Recurrence of epithelial keratitis at graft host junction was seen 3 weeks post penetrating keratoplasty

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Case 4

A 66-year-old one-eyed male patient with a BCVA of light perception (PL) presented with a 6 × 6 mm epithelial defect, mid-stromal infiltrates, thinning, and vascularization in the left eye [Figure 2]d. The ulcer healed over 7 weeks on oral acyclovir with dense scaring and vascularization [Figure 2]e. Six months later, a penetrating keratoplasty was performed for visual rehabilitation. However, in the third postoperative week, the patient developed a geographic ulcer at the graft host junction [Figure 2]f. The patient presented further presented with two episodes of recurrence in the first 6 months following transplantation.

Case 5

A 55-year-old female patient presented with a 7 × 7 mm epithelial defect and a dense mid-stromal infiltrate in an annular pattern was observed [Figure 3]a. BCVA in the left eye was CF at 1 m. A smear examination did not reveal any acanthamoeba cysts and the PCR test for HSV was negative. A presumptive diagnosis of acanthamoeba keratitis was made and the patient was prescribed continue Polyhexamethylene biguanide (PHMB) (0.02%) eyedrops hourly. The patient presented 1 week later with worsening disease [Figure 3]b. On clinical suspicion, oral and topical acyclovir was started and PHMB eyedrops were discontinued. The ulcer responded to oral acyclovir and topical steroid therapy and healed over a period of 4 weeks [Figure 3]c.
Figure 3: (a) Ring-shaped corneal infiltration in a 55-year-old female patient who was diagnosed with acanthamoeba keratitis. (b) The lesion deteriorated while the patient was on anti-acanthamoeba drugs. (c) On clinical suspicion of HSV keratitis, systemic and topical anti-virals were prescribed that led to the complete resolution of the infection over 1 month

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  Discussion Top

HSV keratitis affects both adults and pediatric patients and is potentially blinding. Children are more likely to develop bilateral keratitis, and nearly 40 to 50% of children are reported to have recurrence as compared to nearly 20% of adult patients.[5] Management and prophylaxis guidelines for antiviral suppression in children vary. Colby et al. and Schwartz et al. recommend individualizing the dosage and duration of treatment according to each patient's course.[6],[7] Given the side effects of systemic therapy, dosage, as well as the duration of prophylactic acyclovir treatment, was our concern while managing case 1.

PCR is a widely used modality for HSV detection; however, as seen in cases 1, 4, and 5, the test can be falsely negative. Moreover, the sensitivity of PCR has been reported to be low in patients on antiviral therapy and immune-mediated form of the disease.[8] Simple diagnostic tests such as Giemsa staining of corneal scraping, as was done in case 2, are helpful. Multinuclear giant cells, lymphocytes, and inclusion bodies on Giemsa staining are suggestive of HSV keratitis.[9]

Keratoplasty is a high-risk condition, and these patients were seen to have a higher number of recurrences as was observed in case 4.[10] Similarly, bilateral disease has been reported to be more severe and has frequent recurrences as was observed in cases 3 and 4. Corneal perforations in these cases can be both due to infective and immune-mediated mechanisms. The application of cyanoacrylate glue, as was performed in case 3, is a simple and effective solution. Persistent anesthesia and inflammation can additionally cause impaired re-epithelization in HSV keratitis. Early amniotic membrane transplantation along with tarsorrhaphy, as was performed in case 2, can aid in rapid epithelization as well as prevent collagenolysis.

  Conclusion Top

HSV keratitis has a spectrum of clinical manifestations. Bilateral disease, recurrence, and associated neurotrophic keratopathy can make the disease challenging to manage. Timely diagnosis as well as proper treatment can help in decreasing visual morbidity and sight-threatening complications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Farooq AV, Shukla D. Herpes simplex epithelial and stromal keratitis: an epidemiologic update. Surv Ophthalmol 2012;57:448-62.  Back to cited text no. 1
Wishart MS, Darougar S, Viswalingam ND. Recurrent herpes simplex virus ocular infection: Epidemiological and clinical features. Br J Ophthalmol 1987;71:669-72.  Back to cited text no. 2
Chong EM, Wilhelmus KR, Matoba AY, Jones DB, Coats DK, Paysse EA. Herpes simplex virus keratitis in children. Am J Ophthalmol 2004;138:474-5.  Back to cited text no. 3
Souza PM, Holland EJ, Huang AJ. Bilateral herpetic keratoconjunctivitis. Ophthalmology 2003;110:493-6.  Back to cited text no. 4
Hsiao CH, Yeung L, Yeh LK, Kao LY, Tan HY, Wang NK, et al. Pediatric herpes simplex virus keratitis. Cornea2009;28:249-53.  Back to cited text no. 5
Liu S, Pavan-Langston D, Colby KA. Pediatric herpes simplex of the anterior segment: characteristics, treatment, and outcomes. Ophthalmology. 2012;119:2003-8.  Back to cited text no. 6
Schwartz GS, Holland EJ. Oral acyclovir for the management of herpes simplex virus keratitis in children. Ophthalmology 2000;107:278-82.  Back to cited text no. 7
Pramod NP, Thyagarajan SP, Mohan KV, Anandakannan K. Polymerase chain reaction in the diagnosis of herpetic keratitis: Experience in a developing country. Can J Ophthalmol 2000;35:134-40.  Back to cited text no. 8
Farhatullah S, Kaza S, Athmanathan S, Garg P, Reddy SB, Sharma S. Diagnosis of herpes simplex virus-1 keratitis using Giemsa stain, immunofluorescence assay, and polymerase chain reaction assay on corneal scrapings. Br J Ophthalmol 2004;88:142-4.  Back to cited text no. 9
Lomholt JA, Baggesen K, Ehlers N. Recurrence and rejection rates following corneal transplantation for herpes simplex keratitis. Acta Ophthalmol Scand 1995;73:29-32.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3]


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