Dr. Sandeep Arora FRCS Dr Ashish Nagpal FRCS 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 Study Period Study Population 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; Cultures; Grams Blood Agar Giemsa Sabourad’s KOH Chocolate Agar Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad

Observation Mean duration of treatment 34.57+/-8.7 days 33 eyes of 31 patients Study Population Male Female Sex 19 (61.29%) 12 (38.7%) Mean Age 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 Therapeutic grafting done for perforations in 4 cases. 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, yellow-white 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