307 - Christy Mae Pastolero

NMD3
Ophthalmology

Case:
A 50-year-old male presents with a five-day history of a foreign body sensation and
redness of his right eye. He states that his vision is slightly decreased and that the eye
waters a lot. He has no medical history of note, but recalls having had a problem with
the cornea of the same eye on a previous occasion.

On examination, his visual acuity is 6/9 and his eyelids are normal. The conjunctiva
shows mild, diffuse injection and, on the cornea, you notice a whitish area below the
pupil. The corneal sensation in the right eye is present, but decreased when compared
to that of the left eye. Instillation of 2% fluorescein shows that the whitish area does not
stain, but highlights a branching ulcer on the lateral side of the cornea.

1. Cite 5 differential diagnosis.

1. Bacterial Keratitis
2. Interstitial Keratitis
3. Adenoviral conjunctivitis
4. Recurrent Corneal Erosion
5. Herpes Zoster ophthalmicus

2. What is the most likely diagnosis?

The most likely diagnosis is dendritic ulcer due to herpes simplex virus.

3. Support your most probably diagnosis. Explain briefly.

To diagnose HSV keratitis, one of the key aspects is past infections like history of
recurrent "red eye". Moreover, the hallmark of HSV keratitis is the presence of multiple
small branching epithelial dendrites on the surface of the cornea. The HSV dendrite
possesses terminal bulbs that distinguish it from the herpes zoster pseudodendrite and
follows the nerve pattern of the cornea. Typically, patients with HSV keratitis present
with blurred vision, photophobia, pain, redness, and/or tearing. Visual acuity usually
shows a mild reduction but depends on the location of the infection. A reduction of
corneal sensation when compared to the other side is found in most cases. Examining
the cornea under cobalt blue light after the instillation of 2% fluorescein usually reveals
the typical branched or dendritic ulcer.
4. What is your management?
Topical: Treatment with 3% acyclovir ointment five times a day for 10 days.
Oral: Oral acyclovir 400 mg - 5 times daily for 10 days

5. Briefly explain your management.

Most cases of herpes simplex virus (HSV) epithelial keratitis resolve spontaneously
within 3 weeks. Treatment is usually given to minimize stromal damage and scarring.

- Topical 3% acyclovir ointment is usually administered five times a day for 10 days.
Acyclovir is in a class of antiviral medications called synthetic nucleoside analogues. It
stops the spread of the herpes virus in the body by competing for viral DNA polymerase
and incorporates into the viral DNA to block DNA synthesis and viral replication.

- Oral acyclovir is also an option for patients who are unable to tolerate topical
medications and with good renal function. It is effective as topical antivirals with the
added advantage of no ocular toxicity. Patients with frequent recurrences of ocular HSV
may be placed on a long-term regimen of oral antiviral medication at the prophylactic
maintenance dose. Valacyclovir has been shown to be as effective as acyclovir in
reducing the recurrence of ocular HSV disease.

Moreover, a specialist opinion is required should the lesion not respond to this
treatment.