Transcript Document

Necrotic HSV Keratitis masquerading as Fungal Stromal abscess
‘’Is it common or commonly overlooked”
Dr. Sandeep Arora FRCS
Dr Ashish Nagpal FRCS
Authors have no financial interest.
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Introduction
Corneal stromal inflammation
may be the primary
manifestation of HSV keratitis
or may be seen secondary to
infectious epithelial keratitis,
neurotrophic keratopathy, or
endotheliitis.
The two forms of primary
stromal involvement are
Necrotizing stromal keratitis
Interstitial stromal keratitis.
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Introduction
Destructive Intrastromal
inflammation may lead to thinning
and perforation within a short
period.
The diagnosis of this condition can
pose difficulties if patients present at
later stages of the disease,
especially when associated with
corneal perforation
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Study Design
Retrospective non comparative descriptive case series
Study Period
May 2003 – June 2006
Study Population
Patients on topical antifungal with treatment elsewhere on
presentation diagnosed as having Necrotic HSV Keratitis at
Cornea Services , Retina Foundation , Ahmedabad
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Methodology
Retrospective chart review of all cases of HSV
necrotising keratitis
Patients records were reviewed to ascertain
 Demographic profile like Age, Sex
 BCVA on presentation
 Precipitating factors
 Past history of HSV keratitis,
 Status of other eye
Microbiological work up included
Smears;
Grams
Giemsa
KOH
Cultures;
Blood Agar
Sabourad’s
Chocolate Agar
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
33 eyes of 31 patients
Study Population
Sex
Mean Age
Male
Female
19
(61.29%)
12
(38.7%)
43.7 +/- 9.7 years
(Range 24-63 yrs)
Mean duration of treatment 34.57+/-8.7 days
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
 63.3% had previous history suggestive of Past HSV Keratitis
 21.9% had history of previous scar
 11.7% gave history of some trivial trauma prior to onset
 47.9% had Flu like symptoms prior to onset
• 87.09% instilling mixed topical therapy comprising of
antifungal & antibacterial.
• 12.11% were on Topical antifungal only
• Natamycin & Quinolones were most commonly installed
topical preparations.
• Nearly all were on 1hourly protocol.
Despite this morphology and chronicity of disease all were
comfortable and denied any complaints of intense pain.
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
 Clinically 100% had epithelial defect
which took Rose Bengal stain
 81.8% patients had yellowish stromal
infiltration distributed diffusely with no
well defined margins.
• Intense thinning was noticed in 33.3% eyes
• Perforation with iris show in 12.1% eyes .
• Secondary glaucoma was associated with
79.6% eyes,
All had absent Corneal sensation
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
 57.6% eyes had endothelial involvement in form of
either deposits, or plaques with active KP’s.
Nearly all had intense AC reaction with 69.3% cases
having mean hypopyon of 2.3mm
•All had negative KOH
•Gram +ve Cocci seen in 21.2% smears
•Giemsa revealed presence of multinucleated
giant cells in 57.57%
•All had no growth in culture
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
All were treated with topical and systemic antiviral as per
guidelines determined by Herpetic eye disease trial II.
• Therapeutic grafting done for
perforations in 4 cases.
• 7 eyes had persistent epithelial defect
requiring AMG & tarrsorraphy
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Observation
•On completion of therapy all
scarred down with resulting
leucomas,
•13% cases had recurrence of
disease in next 3- 6 months.
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad
Discussion
Atypical HSV keratitis though uncommon can masquerade as mycotic
keratitis; considering the indolent onset, paucity of symptoms, yellowwhite infiltrate, deeper penetration & associated thinning and in many
imminent perforations.
Application of topical Antifungal along with or without Antibiotics further
aggravates keratitis as it not only compromises ocular surface wellbeing
by inducing preservative toxicity and also uncontrolled viral replication
induced inflammation proceeds in absence of appropriate management.
Simple investigation such as microscopic examination of Giemsa stained
corneal scraping provided a clue to the diagnosis.
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad