Case Studies

Case 3: Red, photophobic eye in a reluctant patient

A 45-year-old woman came in with a 2-day history of red, watery eyes. She also complained of occasional photophobia. She had a history of cold sores as a teenager but was convinced that Ayurvedic remedies had cured her. At the slit lamp, you immediately put in proxymetacaine to relieve her pain. You see some odd-shaped epithelial staining but, more markedly, cells in the anterior chamber. You want to give topical steroids to treat the uveitis.

• 1. Before instilling a topical anaesthetic, what should you have checked?

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  Correct answer: One must always check corneal sensation (the ophthalmic branch of the trigeminal nerve). This can be done by placing the end of a tissue on the cornea and comparing both sides. Causes of corneal anaesthesia include:

  • Herpes simplex
  • Herpes zoster
  • Acanthamoeba
  • Dystrophies
  • Systemic causes
  • Surgery.

• 2. Why must you be careful in only prescribing topical steroids in patients with epitheliopathy of a dendritic nature?

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  Correct answer: If steroids are given alone in patients with dendritic ulcers, these areas can expand together to form a geographic ulcer, which becomes more difficult to treat.

The cornea fellow walks by and kindly offers to examine the patient. His concern is a stromal haze with no necrosis. The patient remembers hearing this term before and recalls that a few years back, she was diagnosed with stromal keratitis.

• 3. Which part of the eye can herpes virus effect?

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  Correct answer: Every part of the eye can be affected:

  • Lids
  • Nasolacrimal system
  • Epithelium, stroma and endothelium of the cornea
  • Sclera
  • Cranial nerves
  • Uvea
  • Vitreous
  • Retina
  • Optic nerve.

  Always suspect herpes infection in any presenting complaint (hence the importance of checking corneal sensation!).

• 4. If this is the second instance of stromal keratitis in this patient, is there a role for prophylactic treatment? What should be given?

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  Correct answer: Stromal keratitis is an inflammatory immune response in the stroma: it is a sight-threatening condition that can occur following epithelial or endothelial involvement. The Herpetic Eye Disease 2 (HED-2) study showed that prophylactic oral acyclovir (ACV) reduced the probability of any form of herpetic disease recurring, although this reduction in probability ceased once treatment was withdrawn. Hence, one should consider oral ACV in this patient at 200 mg twice daily.

She is given topical steroid with both oral and topical acyclovir. A few days later, she comes back with blurred vision: unfortunately, she has not been taking her treatment. Furthermore, she had not told you that she is HIV positive and her CD4 count was 45.

• 5. What condition is she likely to have developed in the posterior pole?

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  Correct answer: Immunocompromised individuals are at risk of developing progressive outer retinal necrosis.

• 6. What treatment would you consider at this stage?

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  Correct answer: Consider using:

  • Intra-vitreal foscarnet
  • Intravenous ACV
  • Perhaps prednisolone by mouth
  • Prophylactic laser (risk of retinal detachment).