Epithelial hypertrophy - an unusual representation of herpes simplex keratitis

Sudhakar Potti; Eswar Rao Sakare

doi:10.4103/ijo.IJO_1369_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 1 | Page : 44-45

Epithelial hypertrophy - an unusual representation of herpes simplex keratitis

Sudhakar Potti, Eswar Rao Sakare
Cornea and Refractive Services, Sankara Eye Hospitals, Guntur, Andhra Pradesh, India

Date of Submission	25-May-2021
Date of Acceptance	28-Aug-2021
Date of Web Publication	07-Jan-2022

Correspondence Address:
Dr. Eswar Rao Sakare
Fellow, Cornea and Refractive Services, Sankara Eye Hospitals, Pedakakani, Guntur, Vijayawada Expressway, Guntur - 522 509, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1369_21

Abstract

Herpes simplex virus (HSV) keratitis is believed to be an important cause of infectious blindness, mainly resulting from stromal opacification. It has multiple manifestations with involvement of the individual layers of the cornea (epithelium, stroma, and endothelium). We report a rare presentation of HSV keratitis, a clinical representation that includes epithelial hypertrophy and subepithelial activity with the appearance of multiple fronds of vessels arising from superficial vascularization with infiltration, which reduced on administration of topical corticosteroids and systemic antivirals. Epithelial hypertrophy also regressed over time.

Keywords: Epithelial hypertrophy, HSV keratitis, sub-epithelial interstitial keratitis

How to cite this article:
Potti S, Sakare ER. Epithelial hypertrophy - an unusual representation of herpes simplex keratitis. Indian J Ophthalmol Case Rep 2022;2:44-5

How to cite this URL:
Potti S, Sakare ER. Epithelial hypertrophy - an unusual representation of herpes simplex keratitis. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Apr 2];2:44-5. Available from: https://www.ijoreports.in/text.asp?2022/2/1/44/334872

Herpes simplex virus (HSV), the most ubiquitous communicable infectious virus in humans, is the causal agent of a wide variety of chronically recurring diseases. HSV keratitis is believed to be an important cause of infectious blindness, mainly resulting from stromal opacification. In adults, the most common clinical presentation of ocular herpes simplex is epithelial/dendritic keratitis, affecting up to 79% of patients.^[1] However, in children, there is evidence that stromal disease is more common.^[2] The current case report represents an unusual way of HSV keratitis presentation.

Case Report

A 12-year-old boy came to the outpatient department with symptoms of redness, itching, pain, watering in both eyes, with diminution of vision, and severe complaints in the left eye. The guardian of the patient gave history of multiple similar episodes in the past, which resolved after taking treatment and recurred over a period of time. Visual acuity in the right eye was 5/60 with − 4.00 Dsph/1.00 Dcyl × 180 improved to 6/9, and unaided visual acuity in the left eye was 5/60 with − 4.00 Dsph/−1.00 Dcyl × 170 improved to 6/24. Intraocular pressure by noncontact tonometry was 17 and 13 mm Hg in the right and left eye, respectively.

On slit-lamp examination, the right eye upper tarsal conjunctiva showed grade 2 papilla (Bonini et al.)^[3] and perilimbal pigmentation suggestive of vernal keratoconjunctivitis. In the left eye, the upper tarsal conjunctiva had grade 1 papilla, perilimbal pigmentation, and on cornea a 4 mm × 3 mm whitish color nodular, vascularized mass in the inferior paracentral area with a 1 mm × 2 mm epithelial defect at the superior margin and mild anterior stromal haze adjacent to the lesion [Figure 1]. Nebular corneal scarring suggestive of ghost scars was present surrounding the lesion. Corneal sensations were reduced. Previous medical records showed history of dendritic epithelial viral keratitis, which resolved after taking topical ganciclovir 0.15% ointment, five times a day for two weeks. The patient did not give any history of tuberculosis or any contact with a tuberculosis-infected person. Laboratory investigations for HIV, HBsAg, and VDRL were done to rule out any systemic diseases and resulted negative. Treatment included loteprednol etabonate 0.5% eye drops 4 times a day and tacrolimus 0.03% eye ointment twice a day in the right eye and acyclovir 3% eye ointment five times a day in the left eye; the patient was asked to follow up.

Figure 1: Figure showing whitish nodular mass at the inferior paracentral area with epithelial defect at the superior margin (arrow mark)

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On the next visit, the patient was feeling symptomatically better with an improvement of vision in the left eye to 6/18(best-corrected visual acuity (BCVA)). On slit-lamp examination, in the right eye, grade 1 papilla in upper tarsal conjunctiva was present, and in the left eye, mild papillary reaction in upper tarsal conjunctiva, healing epitheliopathy, reduction in density of epithelial hypertrophy/subepithelial lesion with appearance of multiple fronds of vessels arising from superficial vascularization was observed [Figure 2]. The patient was counseled to use tacrolimus 0.03% eye ointment twice a day in both eyes and to taper the loteprednol etabonate 0.5% eye drops in the right eye. In the left eye, the patient was advised to use loteprednol acetate 0.5% eye drops six times a day; oral acyclovir 400 mg twice a day was also given.

Figure 2: Figure showing multiple fronds of vessels with infiltration, healed epithelial defect, and minimal adjacent activity

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On the subsequent visit, the patient's vision in the left eye improved to 6/12 (BCVA). On slit-lamp examination, the right eye was apparently normal, whereas in the left eye, the density of subepithelial lesion reduced a lot more, with an appearance of regression toward the limbus. Oral acyclovir 400 mg twice a day was continued; loteprednol etabonate 0.5% eye drops were given 5 times a day in the left eye, and tacrolimus 0.03% eye ointment was given in both eyes as maintenance therapy for vernal keratoconjunctivitis.

After 3 months of prolonged steroid (loteprednol) therapy on tapering doses and oral acyclovir treatment, lesion reduced to 0.5 mm epithelial hypertrophy in the peripheral part of cornea inferiorly with nebular scarring at inferior paracentral area [Figure 3]. Vascularization regressed. BCVA in the left eye improved to 6/6.

Figure 3: Completely reduced lesion with islands of epithelial hypertrophy (arrow mark) and regressed vasculature

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Discussion

According to epidemiological data, HSV keratitis remains a leading infectious cause of blindness in the world. The estimated global incidence of HSV keratitis is roughly 1.5 million, including 40,000 new cases every year.^[4] Herpes simplex virus keratitis has multiple manifestations with involvement of the individual layers of the cornea (epithelium, stroma, and endothelium). It has been established that children tend to have more severe disease, more recurrences, and more secondary corneal scarring and astigmatism, leading to greater reduction of vision.^[2],[5] Patients with atopy have also been noted to have unusually severe HSV keratitis and generally show less therapeutic response to topical antiviral agents than with oral agents.^[6],[7]

In the initial presentation of this patient, clinically we thought of HSV epithelial keratitis, phlyctenular keratitis, and HSV stromal keratitis as differential diagnosis. The patient neither had a history of tuberculosis nor any contact or exposure with a tuberculosis-infected person and presentation of pathology far away from limbus ruled out the etiology of phlyctenular keratitis. Very minimal activity in the stroma ruled out necrotizing stromal keratitis and hence was treated as HSV epithelial keratitis with topical antiviral medication. On the subsequent visit, multiple fronds of vessels appeared with intense infiltration, giving a representation of interstitial keratitis; thus, we started on topical corticosteroids along with systemic antivirals. However, after prolonged treatment with corticosteroids and antivirals, vascularization regressed and it remained as few islands of epithelial hypertrophy, creating a dilemma whether the pathology existed in the epithelium or anterior stroma.

Conclusion

To the best of the author's knowledge, this kind of presentation is a rare form of HSV keratitis, which can be treated with a combination of steroids and systemic antivirals.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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