Herpes Simplex Keratitis Corneal Perforation: A Case Report

Introduction

Corneal perforation forms an important source of ocular morbidity leading to profound visual loss. It accounts for a large number of cases in developing countries and needs immediate surgical intervention. Corneal perforation needs treatment to preserve the integrity of corneal anatomy and to prevent the development of complications such as secondary glaucoma or endophthalmitis.¹

Corneal perforation results from a variety of infectious and noninfectious disorders such as microbial keratitis, trauma, and immune disorders. Temporary measures may be undertaken in the management of corneal perforation and they include the application of a bandage, use of contact lenses, gluing, and amniotic membrane transplantation. Corneal transplantation may be undertaken as a permanent measure of treatment.^2,3.

We present a case of chronic herpes simplex virus keratitis that led to corneal perforation which was successfully managed with Corneal transplantation.

Case Presentation

A 50-year-old female presented to the outpatient department with complaints of pain, redness, and gradual diminution of vision in the right eye. The condition persisted for 20 days. She had received treatment with ciprofloxacin ocular drops earlier. Examination revealed her visual acuity to be restricted to the perception of light. The left eye had a vision of 6/6.

Slit lamp examination of the left eye did not reveal any abnormality. The right eye showed congestion of bulbar conjunctiva. Cornea showed the presence of a paracentral, isolated, large, well-circumscribed, full thickness yellowish-white stromal infiltrate. It measured 4.5 mm X 5.5 mm with a central 2 mm perforation. The anterior chamber was shallow. Two sutures were used to seal the perforation. However, post-procedure shallow anterior chamber was noted suggestive of an incomplete seal (Fig 1).

Microbiological evaluations were carried out using corneal samples for the presence of fungi, bacteria, and acanthamoeba species. Gram-stained smears did not reveal the presence of any microorganisms. Multinucleated giant cells with distinctive molding of nuclei were observed under Giemsa stain suggesting infectious keratitis most possibly of a viral etiology Potassium hydroxide preparation of the scrapings did not reveal any fungi.

As there was no improvement in the condition over two weeks, the patient underwent a therapeutic keratoplasty. She was prescribed oral acyclovir 400 mg five times a day with 1% prednisolone acetate eye drops 6 times a day. There was an improvement in visual acuity and was 6/60. No recurrence occurred and the graft was clear during 4 months postoperative follow-up period (Fig. 2).

Discussion

Corneal perforation may occur from traumatic on non-traumatic causes. Non-traumatic conditions may be of infectious or non-infectious etiology. Bacterial, fungal, viral, or parasitic conditions can lead to corneal perforation. Non-infectious etiological conditions include ocular surface conditions such as keratoconjunctivitis sicca or autoimmune disorders such as peripheral ulcerative keratitis secondary to rheumatoid arthritis, Mooren’s ulcer, Wegener’s granulomatosis, and relapsing polychondritis.⁴

Herpes simplex virus (HSV) stromal keratitis leading to perforation is infrequently seen. The condition is known for its chronicity and slow response to medication. The diagnosis of atypical HSV keratitis poses many difficulties. The present case was non-viral keratitis in the background of rapid advancement of the symptoms.

Giemsa stain of the corneal scraping showed the presence of multinucleated giant cells with characteristic nuclear molding. It suggested a viral etiology. Polymerase Chain Reaction (PCR) is recommended to diagnose atypical presentation of herpetic ocular diseases.⁵

Many predisposing factors such as the use of contact lenses, poor fitting lenses, inadequate lensed hygiene, and micro trauma have been ascribed for an atypical presentation leading to recurrence of herpetic keratitis. The present case highlights that HSV keratitis can appear as a perforated corneal ulcer with a large infiltrate. Conjunctival scrapings may be used to detect viral antigens if there is difficulty in collecting corneal scrapings.

A high degree of suspicion is needed to establish a viral etiology of corneal perforation. Giemsa stain of corneal scrapings is useful in the diagnosis. Prompt use of prophylactic antiviral agents would be valuable in such conditions. There should not be any delay in surgical treatment with full thickness keratoplasty when there is corneal perforation.

Conflicts of Interest

Nil