Clinical and Demographic Characteristics of Herpetic Keratitis Patients-Tertiary Centre Experience.

Background and Objectives: Herpes simplex keratitis (HSK) is the leading infectious cause of corneal damage and associated loss of visual acuity. Because of its frequent recurrence, it represents a major health problem; thus, timely and accurate diagnosis is the key to successful treatment. To enable this, we aimed to determine HSK patients' demographic and clinical features. Materials and Methods: This prospective study included 55 patients diagnosed with HSK between March 2019 and August 2022 at the Department of Ophthalmology, Clinical Hospital Rijeka. Results: We found that HSK is most prevalent in the elderly, with 72.73% of patients older than 60. The most common HSK types were dendritic (HSK-D; 43.64%) and stromal with epithelial ulceration (HSK-SEU 23.64%). HSK recurrences occurred in 65.45% of patients, with most having two to five recurrences (55.56%). Visual acuity at presentation (65.5%) and after treatment (50.9%) was mostly in the 20/50 range. The longest period until the disease symptoms were resolved was in the group with stromal HSK without epithelial ulceration (HSK-SnEU), for which symptoms lasted more than 11 weeks in 87.5% of patients. The overall incidence of HSK-related complications was high (85.45%), with 76.4% of patients having corneal scarring. The average time from symptom to treatment was 15.78 days. Interestingly, we observed a strong seasonality in the incidence of HSK, which was most prevalent in the colder months, with 63.6% of cases occurring between October and March. Conclusions: To the best of our knowledge, this is the first prospective study in Croatia, and one of the few in Europe, to describe the demographic and clinical features of HSK patients. We found that HSK is most common in the elderly population, with its dendritic form as a clinical presentation. We have shown that HSK is prone to recurrence and secondary complications, with a worryingly long time between symptom and treatment, indicating the need for diagnostic testing in routine practice.

[Recurrent herpetic erosion of the cornea: diagnosis, treatment and prevention of recurrences]. / gerpeticheskaya retsidiviruyushchaya eroziya rogovitsy: diagnostika, lechenie i preduprezhdenie retsidivov.

A group of patients was found to have a special form of recurrent corneal erosion caused by types I and II herpes virus. This form represents an independent form of ophthalmic herpes - herpetic recurrent erosion (HRE) of the cornea. The herpetic etiology of recurrent corneal erosion was confirmed by the immunofluorescence study of scraping from the conjunctiva, which revealed a high concentration of the herpes simplex virus antigen. Treatment of patients (171 patients, 182 eyes) with HRE included 2 consecutive stages: stage I - relief of acute symptoms of the disease with the help of conservative treatment (instillations of interferon inducers, autologous serum, corneal protectors, tear substitutes, use of therapeutic soft contact lenses); in some cases, phototherapeutic keratectomy was used in the absence of the effect of conservative therapy, as well as in the localization of the focus in the optical zone. Stage II involved anti-relapse therapy based on the use of a Russian-produced herpes vaccine in the intercurrent period. After vaccination, observation for 2 years or more showed that 81.3% of patients achieved clinical recovery (complete cessation of HRE recurrences), 15.8% had a decrease in the frequency and severity of relapses, while 2.9% of patients did not respond to the treatment.

Diagnostic performance of real-time quantitative PCR in tear samples in various subtypes of herpes simplex keratitis.

Diagnosis of herpes simplex keratitis (HSK) is mostly based on clinical findings, yet biological confirmation supports management of challenging cases. This study evaluated the place of real-time quantitative PCR (RT-qPCR) on tear samplings in the management of HSK. Clinical records of patients who underwent tear sampling tested by RT-qPCR for herpes simplex virus type 1 for an acute episode of corneal inflammation or defect between January 2013 and December 2021 were retrospectively reviewed, and results were compared to clinical diagnosis (i.e., HSK or not) based on biomicroscopic findings and medical history. Of 465 tested tear samples from 364 patients, a clinical diagnosis of active (ongoing) HSK was recorded in 240 cases, among which 76 were RT-qPCR positive (global sensitivity of 31.6%, specificity of 99.5%). Sensitivity of RT-qPCR was higher in epithelial (97.4%) and stromal keratitis with ulceration (48.7%), compared to other types of HSK (23.5% in keratouveitis, 13.6% in endotheliitis, 11.1% in postherpetic neurotrophic keratopathy, and 8.1% in stromal keratitis without ulceration). The highest viral loads were detected from epithelial and stromal keratitis with ulceration, while in HSK with no epithelial involvement, the viral load detected was 196-fold lower, on average. The proportion of clinically characterized HSK patients with negative tear samples was higher in patients receiving antiviral treatment (P < 0.0001). RT-qPCR, performed on tear samples, can help in confirming diagnosis in case of presumed HSK, including clinical forms with no obvious epithelial involvement. The sensitivity of tear sampling is much higher whenever epithelial keratitis is present.

Rapid detection and diagnosis of herpetic keratitis using quantitative microfluidic polymerase chain reaction system for herpes simplex and varicella-zoster virus DNA: a case series.

BACKGROUND: A microfluidic real-time polymerase chain reaction (PCR) system can rapidly detect the viral DNA in specimens. Detection of herpes simplex virus (HSV) and varicella-zoster virus (VZV) DNA in tears is a useful diagnostic tool for herpes simplex virus keratitis (HSK) and herpes zoster ophthalmicus (HZO). METHODS: In total, 20 patients were included in this cross-sectional study. Among them, 8 patients with infectious epithelial HSK and 12 patients with HZO were included in HSK and HZO groups, respectively. In addition, 8 patients with non-herpetic keratitis and 4 healthy individuals without keratitis were included in the control group. Numbers of HSV and VZV DNA copies in tears of all patients and individuals were evaluated using a microfluidic real-time PCR system. Regarding HSV/VZV DNA test, tear specimens were collected by filter paper method using Schirmer's test paper, and subsequently, DNA was extracted from the filter paper using an automated nucleic acid extractor. Afterward, quantitative PCR was performed using a microfluidic real-time PCR system. RESULTS: From tear collection to real-time PCR result determination, the HSV/VZV DNA test took approximately 40 min. In the HSK group, the sensitivity and specificity of the HSV DNA tests were 100% each. The median value (range) of number of HSV DNA copies for affected eyes was 3.4 × 105 copies/µL (under a lower detection limit of 7.6). In the HZO group, the sensitivity and specificity of the VZV DNA tests were 100% each. The median value (range) of number of VZV DNA copies for affected eyes was 5.3 × 105 copies/µL (under a lower detection limit of 5.6 × 10-2). CONCLUSION: In conclusion, quantitative PCR for HSV and VZV DNA in tears using a microfluidic real-time PCR system is useful for diagnosing and monitoring HSK and HZO.

New-Onset of Herpes Simplex Keratitis After Blepharoplasty, Case Series and Review of the Literature.

PURPOSE: To report 3 cases of new-onset herpes simplex keratitis (HSK) after uncomplicated extraocular plastic surgery and discuss potential risk factors. METHODS: This case series includes 3 patients who underwent uncomplicated blepharoplastic surgery. Within 2 weeks postoperatively, all patients reported ocular discomfort, and their ophthalmic examinations revealed corneal lesions suspicious of HSK. One case was confirmed as an active herpes infection, and the other 2 cases were clinically diagnosed with HSK. The patients were treated with oral acyclovir and followed up for up to 6 weeks. RESULTS: All patients demonstrated improvement without sequelae at follow-up visits from 5 days to 4 weeks after initiating acyclovir treatment. CONCLUSIONS: Risk factors for new-onset HSK after uncomplicated extraocular surgeries may be related to an immunocompromised state, postoperative administration of topical or periocular corticosteroids, or environmental factors such as psychological stress. Ophthalmologists, particularly plastic surgeons, should be vigilant for ocular discomfort following eyelid surgeries and consider the possibility of herpes infection. This report highlights the importance of recognizing and managing HSK in the context of extraocular plastic surgery.

Bilateral Thygeson's Superficial Punctate Keratitis with Dendritic Corneal Lesion: A Case Report.

Thygeson's superficial punctate keratitis (TSPK) is a recurrent bilateral corneal epithelial disease. Typically, small, multiple discrete epithelial lesions occur in the central cornea. However, dendritic corneal lesions are rare. Herein, we report a rare case of TSPK in both eyes after a unilateral dendritic corneal lesion. A 42-year-old woman presented with decreased vision and foreign body sensation in her right eye that persisted for 1 month. Her uncorrected visual acuity and best-corrected visual acuity (BCVA) were 20/160 in the right eye. Slit-lamp microscopy revealed a dendritic lesion in the central cornea of the right eye. No abnormalities were observed in her left eye. Herpetic keratitis in the right eye was diagnosed and systemic acyclovir was prescribed, along with topical acyclovir ointment and steroids. After one week, most of the corneal lesions had disappeared, and the BCVA in the right eye had improved to 20/25. The corneal epithelium completely recovered after 2 weeks. However, 2 weeks later, the patient visited the hospital with decreased visual acuity in the right eye, and the BCVA decreased to 20/40. Multiple fine corneal lesions were observed under a slit-lamp microscope. The patient was diagnosed with TSPK of the right eye. Topical steroids were started, and after 7 days, the corneal condition improved. However, after 6 weeks, visual acuity decreased in the left eye, and a corneal lesion similar to that in the right eye was observed; therefore, the patient was diagnosed with bilateral TSPK. Short-term topical steroids and long-term topical cyclosporine A 0.1% were used in both eyes, and the disease was maintained without recurrence for 3 months. TSPK can appear as a unilateral dendritic corneal lesion similar to herpetic keratitis. Therefore, in case of unilateral dendritic corneal lesions, it should be considered that TSPK may develop later.

Herpes simplex virus keratitis: electronic medical records driven big data analytics report from a tertiary eye institute of South India.

OBJECTIVE: To describe the demographics and clinical profile of Herpes Simplex Virus (HSV) Keratitis in patients presenting to a multi-tier ophthalmology hospital network in South India. METHODS: We have reviewed the medical records of all patients having a clinical diagnosis of any form of HSV keratitis, seen between May 2012 and August 2020 across the L V Prasad Eye Institute network. All the further analyses of the groups were performed using the keywords used for making the diagnosis of HSV keratitis and the data were collected from the electronic medical record system. RESULTS: There were a total of 8308 (N = 8897 eyes) patients. Male: female ratio was 5368 (64.61%):2940 (35.39%). Unilateral involvement was in 7719 (92.91%) patients. The most common age group affected was between the third to fifth decades of life with 1544 (18.58%). 3708 (1.68%) eyes had mild visual impairment (< 20/70) while the rest of them had moderate to severe visual impairment as observed mainly (p ≤ 0.01) in Necrotizing stromal keratitis. 7314 (82.21%) eyes had normal intraocular pressure (10-21 mm Hg) while raised most commonly in keratouveitis (P ≤ 0.01). Epithelial Keratitis, Immune Stromal Keratitis, Endotheliitis, Neurotrophic keratopathy and Keratouveitis were observed in 1875 (17.22%) eyes, 5430 (61.03%) eyes, in 129(1.45%) eyes, 1188 (13.35%) eyes, 148 (1.66%) eyes and 256 (2.88%) eyes respectively. CONCLUSION: Based on our institute-based data, the most common type of HSV keratitis is Immune stromal keratitis followed by epithelial keratitis. Although not representative of the general population, this data provide useful insights related to HSV keratitis from India.

[Chinese expert consensus on the diagnosis and treatment of herpes simplex keratitis (2023)].

As one of the common infectious corneal diseases, herpes simplex keratitis (HSK) has diverse clinical manifestations, is prone to recurrence, and can lead to blindness. In recent years, as new virus detection technologies, treatment drugs and surgical methods have emerged, there are more options for the diagnosis and treatment of HSK, but many problems still exist. In order to further standardize the clinical diagnosis and treatment of HSK and provide guidance and reference for clinical work, the Ocular Infection Group of Chinese Ophthalmologist Association has gathered relevant domestic experts, and reached this consensus on the diagnosis, treatment, and prevention of HSK through full discussion, on the basis of previous opinions, and in consideration of the latest research progress, relevant guidelines abroad and expert recommendations regarding the clinical care of patients with HSK.

Herpetic uveitis caused by herpes simplex virus after cataract surgery in a patient without prior viral keratitis or uveitis: a case report.

BACKGROUND: To report a case of herpetic uveitis caused by herpes simplex virus after cataract surgery in a patient without prior viral keratitis or uveitis. CASE PRESENTATION: A 70-year-old female was referred to our clinic with a 16-day history of acute blurry vision with painful redness in the right eye. She accepted cataract surgery for the right eye ten days before initial of ocular symptoms. There was significant inflammation in anterior chamber of the right eye. Retina exam showed moderate dense vitreous opacity but not necrotic or focal retinal lesion in the right eye. The aqueous humor collected from the right eye was positive for herpes simplex virus (HSV) DNA by PCR. The diagnosis of herpetic uveitis in the right eye was made due to clinical presentations and aqueous humor examination. CONCLUSION: Herpetic virus reactivation might occasionally occur after intraocular surgery in patients without prior ocular viral diseases, inducing atypical postoperative intraocular inflammation.

Herpes simplex keratitis following Smart Pulse Technology assisted transepithelial photorefractive keratectomy: a case report.

BACKGROUND: Herpes simplex keratitis (HSK) is a rare and sight-threatening complication following refractive surgery. SmartSurfACE surgery is the result of combining transepithelial photorefractive keratectomy (trans-PRK) with Smart Pulse Technology (SPT) to diminish surface irregularities of the residual stromal bed after surgery with less pain, faster re-epithelialization, and better postoperative visual acuity. In this article, we report the first case of HSK following SmartSurf ACE without history of herpetic eye disease. CASE PRESENTATION: A 21-year-old woman underwent bilateral SmartSurfACE without history of clinical herpetic infection, active eye disease, or systemic disease. Mild superficial punctate keratitis occurred on the tenth postoperative day. The condition was not improved by ophthalmic drugs of anti-inflammation or epithelial healings. Dendritic corneal ulcer appeared within one month, which is the commonly recognized clinical manifestation of herpes simplex keratitis. The patient was managed with topical and systemic antiviral agents. After nine days of antiviral therapy, the lesion healed up, remaining mild stromal scarring in both eyes ultimately. CONCLUSION: Herpes simplex keratitis is a rare but sight-threatening complication following refractive surgery. For the ocular irritation symptoms of postoperative patients, we should consider the possibility of HSK and give timely treatment.

Epstein-Barr viral corneal stromal keratitis occurring during rheumatoid arthritis treatment: a case report.

BACKGROUND: A case of Epstein-Barr viral (EBV) corneal stromal keratitis during rheumatoid arthritis (RA) treatment is presented. CASE PRESENTATION: A 74-year-old female undergoing RA treatment was previously treated for bacterial corneal ulcer and herpetic keratitis and healed with antibiotic eye drops and topical anti-herpes ointment. At the first visit to our hospital, she presented with findings of monocular posterior interstitial keratitis with neovascularization mostly located in the inferior cornea with a corneal epithelial defect. The right eye showed no thinning of the corneal periphery and anterior uveitis. Her RA had subsided with oral steroid treatment, and infectious mononucleosis (IM) had not developed. EBV DNA could be detected in her corneal sample. After an extended but ineffective period to antibiotic treatment the corneal infiltrate responded rapidly to topical corticosteroids. CONCLUSION: EBV can cause stromal keratitis without IM during treatment for RA.

Clinical outcomes of herpes simplex keratitis: Two-year experience from a quaternary eye care centre in Sydney, Australia.

PURPOSE: To report anti-viral therapy and outcomes for patients with herpes simplex keratitis (HSK) in a quaternary centre in Sydney, Australia. METHODS: A retrospective case review of patients who received anti-viral medications for any form of HSK was conducted. Cases were identified from pathology results, pharmacy records and hospital coding data from 2012 to 2013. Clinical details including initial anti-viral treatment and outcome were collated from the medical records. Outcome was determined from when initial anti-viral treatment was stopped or changed, and classified as either clinically resolved, partially resolved or worsened for therapeutic indication; or as either success or failure for prophylaxis. RESULTS: Anti-viral therapy was given for therapeutic and prophylactic indications at presentation in 252 (85%) and 44 patients (15%), respectively. Topical aciclovir five times daily and valaciclovir in doses ranging from 500 mg to 1 g, one to three times daily were the preferred anti-viral therapies. One hundred and fourteen patients (n = 114/296, 38.5%) also received topical corticosteroids. An outcome was determined for 210/296 (71%) patients. For therapeutic indication, half of the patients (90/174) partially resolved within 8 days, with best outcomes achieved for endothelial HSK (8/11, 73%) and keratouveitis (21/36, 58%). Adverse events, observed in 20% (35/174) of patients, included corneal perforation (n = 8) and secondary bacterial keratitis (n = 6). Prophylaxis with antiviral therapy was successful in two-thirds of patients after 6 months. CONCLUSIONS: Clinical and visual outcomes varied with the type of HSK and prescribed therapies. Diverse initial anti-viral therapies were identified; standardising them may improve outcomes.

Herpes Simplex Virus Keratitis in a University Tertiary Referral Centre - Clinical Features and Surgical Approaches.

PURPOSE: To assess prevalence, clinical manifestations, required keratoplasties, follow-up, and outcome in patients with Herpes Simplex Virus Keratitis (HSK) attending a University Tertiary Referral Center. DESIGN: Retrospective (12 years), descriptive, observational study. METHODS: A total of 817 eyes with clinical diagnosis of HSK from 779 patients were classified by the type of presentation. We gathered data on the visual acuity, refraction, IOP, and required surgical procedures. RESULTS: Stromal involvement including scars represented the most common diagnosis in our department and the main indication of penetrating keratoplasty (PKP). Epithelial keratitis (16%) presented with the best visual acuity at the first visit. Necrotizing keratitis represented 17% of the patients, 78% of whom required PKP; this group also had the worst visual acuity at first examination and was the main indication for emergency PKP. Among all eyes, 288 (35%) required PKP. A total of 230 (28%) PKPs were elective procedures and 58 (7%) PKPs were performed as emergency procedures. Two patients with quiet endothelial decompensations after recurrent HSV endotheliitis were treated with DMEK and had good visual outcomes without HSV recurrence at last follow-up. CONCLUSIONS: HSK is a prevalent disease with severe consequences when not treated appropriately and on time. Even when making an accurate diagnosis, the disease can be extremely aggressive, with all the implications it brings to the patients and health system. Elective PKP had better outcomes in terms of visual acuity and clear graft percentage compared to emergency PKP.

Herpes Simplex Keratitis in Patients with SARS-CoV-2 Infection: A Series of Five Cases.

Herpes simplex virus type 1 (HSV-1) is a leading cause of infectious blindness worldwide. Most of the initial infection cases manifest as acute epithelial keratitis. Reactivation of herpesviruses is common in critically ill patients, including patients with severe Coronavirus disease (COVID-19). However, the data on COVID-19-related ocular infections is sparse, despite recent observations that more than 30% of COVID-19-infected patients had ocular manifestations. We report five cases of HSV-1 keratitis in COVID-19 patients. In total, five COVID-19 patients underwent ophthalmic examination, showing similar symptoms, including photophobia, tearing, decreased vision, eye redness, and pain. After initial assessment, tests of visual acuity and corneal sensitivity, a fluorescein staining test, and complete anterior and posterior segment examinations were performed. A diagnosis of HSV-1 keratitis was confirmed in all cases. Therapy was initiated using a local and systemic antiviral approach together with local antibiotic and mydriatic therapy. The complete reduction of keratitis symptoms and a clear cornea was achieved in all patients within 2 weeks. SARS-CoV-2 infection may be a risk factor for developing HSV-1 keratitis, or it may act as a potential activator of this ocular disease.

Quantitative real-time polymerase chain reaction analysis in herpes simplex virus keratitis with and without epithelial involvement.

PURPOSE: To evaluate the quantitative real-time polymerase chain reaction (qRT-PCR) analysis in herpes simplex virus (HSV) keratitis with and without epithelial involvement. METHODS: This cross-sectional study was performed on 70 patients with different HSV types and an active ocular lesion in Farabi Eye Hospital, Tehran, Iran. From these 70 patients, 171 samples were collected, including seventy tear samples and 33 scraping samples from involved eyes; and 68 samples from uninvolved fellow eyes. Samples were frozen at - 70 °C until DNA extraction was performed. Quantity of HSV was measured using qRT-PCR in all three samples. RESULTS: The mean age of HSV patients was 52.19 ± 20.42 years (range, 4-85 years). Forty-one (58.6%) HSV patients had epithelial involvement, and 29 (41.4%) patients did not have epithelial involvement. In PCR-positive cases, the mean number of viruses in affected eyes' tears (8,831,234 ± 4,051,979) was significantly higher than uninvolved eyes' tears (182,603 ± 69,141) (P = 0.02). The mean of PCR in HSV patients with and without epithelial involvement was 10,320,269 ± 5,329,800 and 1,469,419 ± 1,070,396, respectively (P = 0.04). The qRT-PCR of involved tears in both groups (with and without epithelial involvement) was significantly higher than unaffected eyes' tears (P < 0.0001 and P = 0.01, respectively). In cases with and without epithelial involvement, the cutoff points of viral load in involved eyes' tears were 281,000 and 126,000 copies, respectively. CONCLUSION: The results indicated that qRT-PCR is an excellent method for the detection of herpes simplex keratitis.

Fetal and neonatal abnormalities due to congenital herpes simplex virus infection: a literature review.

OBJECTIVE: Herpes simplex virus (HSV) infection during pregnancy can cause severe neonatal infections. It is also a rare cause of congenital infections. We aimed to describe fetal and neonatal abnormalities of congenital HSV infection in order to define the features that are accessible to prenatal diagnosis during ultrasound screening and/or during a work-up for congenital malformations. METHODS: We analysed all cases of congenital HSV infection (CHI) described before and/or after birth and identified in Pubed and classified the findings as accessible or not to prenatal diagnosis. RESULTS: Thirty-six cases of congenital herpes infection were reported, of which 15 were described prenatally and 21 postnatally. The most frequently reported malformations accessible to prenatal diagnosis were cerebral anomalies. The most common abnormalities described after birth were skin lesions and keratitis, which are not considered amenable to prenatal ultrasound detection. CHI can due to either HSV1 or HSV2 infection, whether primary or non-primary infection, with or without the presence of maternal symptoms. CONCLUSION: Prenatal ultrasound abnormalities due to CHI are rare, varied and non-specific. There is no clear role for fetal ultrasound in the routine management of women with primary or non-primary HSV infection in pregnancy. However, in fetuses with ultrasound abnormalities suggestive of congenital infection, HSV should still be considered as a differential diagnosis after the more common in utero infections, such as cytomegalovirus, are excluded.

Comparative analysis of the tear protein profile in herpes simplex virus type 1 epithelial keratitis.

BACKGROUND: Herpes simplex virus type 1 (HSV-1) keratitis is a major cause of corneal blindness in the world, and an in-depth understanding of its pathogenesis may help improve existing diagnosis and treatment. The purpose of this study is to compare and analysis the total tear protein profile of HSV-1 epithelial keratitis patients, and to quantify the potential candidate biomarkers of HSV-1 epithelial keratitis. METHODS: We investigated the proteome in tear fluid from three HSV-1 epithelial keratitis patients and three healthy control subjects using nano-scale liquid chromatography-tandem mass spectrometry (nLC-MS/MS) analysis. Functional annotation of differentially expressed proteins was done with the Gene Ontology (GO) analysis. ELISA was done to quantify the potential candidate biomarkers in 26 clinical cases. RESULTS: Tear fluid from three HSV-1 epithelial keratitis patients and three healthy control subjects contained a total of 1275 proteins and 326 proteins were unique to tear fluid of HSV-1 epithelial keratitis patients. Bioinformatics analysis revealed that tear proteins from HSV-1 epithelial keratitis patients may be involved in metabolic processes, antigen presentation, inflammatory response, and in the TNF-mediated and T cell receptor pathways. Furthermore, IL1A, IL12B, DEFB4A, and CAMP, which are associated with the inflammatory response and inhibition of viral infection, were significantly more abundant in the HSV-1 epithelial keratitis patients than in the healthy control subjects. CONCLUSIONS: This study reports the proteomic profile of tears in HSV-1 epithelial keratitis for the first time and identifies a number of unique differentially expressed proteins.

Corneal Endotheliitis as a Presentation of Acanthamoeba Keratitis.

OBJECTIVE: To report 2 cases of Acanthamoeba keratitis (AK) presenting with corneal endotheliitis. METHODS: Case report. RESULTS: Two contact lens wearers, who had been diagnosed with herpes simplex virus (HSV) keratitis, predominantly manifested corneal endotheliitis composed of corneal edema, keratic precipitates, and anterior chamber reaction at referral. AK was confirmed using cultures or through polymerase chain reaction testing. The patients were started on polyhexamethylene biguanide and responded favorably to regain satisfactory visual acuity. CONCLUSIONS: Corneal endotheliitis, although uncommon, may be a manifestation of AK. We must have high-index suspicion for AK in all contact lens users, particularly before making a diagnosis of HSV keratitis. Accurate diagnosis and prompt treatment can result in a favorable prognosis for AK.

Utility of HSV Serology for Chronic Corneal Pathology.

OBJECTIVES: The purpose of this study is to determine the utility of obtaining herpes simplex virus (HSV) serology for patients presenting with chronic corneal pathology of unknown etiology for which HSV is a diagnostic consideration. METHODS: A retrospective analysis was performed of all patients presenting to one cornea specialist (J.M.G.) between August 2011 and April 2018 with a chronic (>6 weeks) corneal condition for which HSV was suspected and serology was performed. Patient demographics, clinical presentation, treatment, final diagnosis, and follow-up duration were recorded. RESULTS: Fifty-four patients with a median age of 52 (range: 5-85) years were included in the study. Patients were classified by presenting clinical features as corneal ulcer (46.2%), stromal keratitis (24.1%), superficial keratitis (18.5%), or keratouveitis (11.1%). The seroprevalence of HSV-1 and HSV-2 antibodies were 42.6% and 18.5%, including 5 patients (9.3%) positive for both HSV-1 and HSV-2. Serology impacted management for all patients with negative titers (48.1%), defined as discontinuing antiviral medication, electing not to start antiviral medication, or continuing antiviral medication for a non-HSV etiology (e.g., varicella zoster keratitis). No patients with HSV serology were ultimately diagnosed with HSV keratitis. Median follow-up duration was 1.5 years (range 0.8-6.6 years). CONCLUSION: Although only useful when negative, our study confirms that serology may be useful for excluding HSV as a diagnostic consideration for patients presenting with chronic corneal pathology. The seroprevalence of HSV antibodies for our patient cohort was comparable with previous population-based studies.

A Case of Reactivation of Herpes Simplex Virus Corneal Endotheliitis Following Periocular Botulinum Toxin A Injection.

Botulinum toxin type-A is a standard treatment of a variety of neurological disorders. Here, the authors report a rare ocular adverse effect after periocular Botulinum Toxin-A injection for hemifacial spasm. Three weeks after the injection, facial spasm was relieved, but the patient had dimness of vision OS. Examination revealed corneal edema, anterior-chamber reaction, keratic precipitates, and elevated intraocular pressure in OS suggesting reactivation of herpes simplex viral endotheliitis with trabeculitis. The case was successfully treated with oral acyclovir (400 mg) and topical fluorometholone 0.1% for 6 weeks. Pre- and posttreatment anterior segment optical coherence tomography clearly demonstrated the evidence of keratic precipitates. To the best of the authors' knowledge, this is the first report of herpetic reactivation in the form of corneal endotheliitis with trabeculitis after Botulinum toxin-A injection. The aim of reporting this case is to alert the clinician about the possibility of such consequence of botulinum toxin injection.