1. Department of Cornea, Cataract & Refractive Surgery and *Ocular Microbiology Dr Rajendra Prasad Centre For Ophthalmic Sciences, AIIMS Dr. Manoj Sharma, MD Radhika Tandon, MD, DNB, FRCS, FRCOphth Dr Gita Satpathy, MD* The authors have no financial interest in the subject matter of this poster

2. To report the clinical features and management outcome in two patients with bilateral diffuse herpetic endotheliitis

3. Two patients presented with acute onset bilateral diminution of vision ocular pain, redness, and photophobia Case 1: 65-year-old male with vision of 6/36 (OU) Case 2: 55-year-old male with vision of 1/60 (OU) & past history of keratitis in one eye (OS)

4. Bilateral Circumcorneal congestion, diffuse stromal oedema, Descemet folds, keratitic precipitates and anterior chamber reaction Reduced corneal sensations Normal IOP Case 1 1b 2a 2b Diffuse Slit 1a

5. Bilateral Circumcorneal congestion, diffuse stromal oedema, Descemet folds, keratitic precipitates and anterior chamber reaction Reduced corneal sensations Normal IOP Left eye had an additional superficial opacity (arrow) Diffuse Slit Case 2

6. Tear samples from case 1 were negative and case 2 positive for HSV DNA in both eyes Complete resolution of inflammation and oedema occurred in both cases with treatment Lane 1-4 : Clinical samples Lane M: 100 bp DNA ladder Lane 5: Clinical sample Lane 6: Positive control Lane 7: Negative control Lane 1-4 : Clinical samples Lane M: 100 bp DNA ladder Lane 5: Clinical sample Lane 6: Positive control Lane 7: Negative control 1 2 3 4 M 5 6 7

7. Oral acyclovir was continued for 6 mths to prevent recurrence No recurrence was noted during 12 months follow-up Patients regained vision & maintained BCVA at 12 months 6/6 (OU) case 1 6/6(OD) and 6/9 (OS) case 2 Case 2 Case 1 Clinical Photographs of both patients after 12 month follow up

8. Before starting treatment tear samples from both eyes of patients were collected by fire polished microcapillary tube and subjected to PCR for HSV DNA detection PCR Protocol 1. DNA extraction: commercial QI Amp DNA blood kit 2. Polymerase chain reaction Primer-111 bp region of HSV 1 thymidine kinase gene (Hofgartner W T et. al Clinical chemistry, 1999) Amplification- thermal cycler (Gene Amp PCR system 9700, applied biosystem, USA) 3. Electrophoreses- in 2% agarose gel

9. Tab acyclovir 400 mg (5 times/day) × 7 days Tab acyclovir 400 mg (BD) × 6 months Topical steroid (1% prednisolone acetate) Adjunct therapy was given as required Topical antibiotic Topical mydriatic (2% homatropine) Topical lubricant (preservative free) Analgesics (if required)

10. HSV-1 may cause bilateral diffuse corneal endotheliitis, Therefore it should be regarded as a manifestation of HSV 1 corneal infection High index of suspicion is required in such cases and patients treated appropriately PCR in tear samples may be helpful and serve as a non invasive diagnostic tool in some cases

11. Dr Radhika Tandon Professor of Ophthalmology radhika_tan@yahoo.com Dr. RP Centre for Ophthalmic Sciences, AIIMS New Delhi 110029 India