Herpes simplex virus bullous keratitis misdiagnosed as a case of pseudophakic bullous keratopathy with secondary glaucoma: an unusual presentation
To report an unusual case of herpetic bullous keratitis misdiagnosed as a case of pseudophakic bullous keratopathy with secondary glaucoma.
A retrospective analysis of the case record of a 60-year-old man who had earlier undergone bilateral cataract surgery, was done. He presented with a complaint of decrease in vision in the right eye of 20 days duration. On examination, cornea showed epithelial bullae all over the surface with stromal and epithelial edema. Intraocular pressure was 30 mm of Hg in RE. He was treated with anti-glaucoma medications. Two dendritic lesions were seen in the cornea during a subsequent visit four days later. Virological investigations confirmed a diagnosis of Herpes simplex keratitis. He was treated with topical acyclovir.
This case highlights the fact that herpes simplex keratitis can present initially as a more diffuse corneal stromal and epithelial edema with epithelial bullae mimicking bullous keratopathy. Herpetic bullous keratitis, although unusual, should be considered in the differential diagnosis under such circumstances.
KeywordsIntraocular Pressure Keratitis Multinucleated Giant Cell Corneal Edema Secondary Glaucoma
Herpes simplex keratitis (HSK) is a sight threatening ocular infection and is a leading cause of corneal blindness . Clinical presentation of HSK is often protean. While a typical and common presentation of HSK is usually a dendritic or geographic ulcer, atypical presentations are not uncommon . We report here an unusual presentation of HSK. The patient presented to us with bullous keratitis, which was misdiagnosed as a case of pseudophakic bullous keratopathy (PBK) with secondary glaucoma.
This case was initially diagnosed as PBK with secondary glaucoma based on a history of cataract surgery, presence of diffuse corneal stromal and epithelial edema, epithelial bullae and a raised intraocular pressure in the affected eye. The subsequent appearance of typical dendritic lesions and virological investigations confirmed a diagnosis of herpetic bullous keratitis. Further, the present event occurred after 4 years after the cataract surgery. Since corneal latency of HSV has been described , it is perfectly reasonable to assume that herpes rather than the previous endothelial damage caused the whole syndrome.
The presence of glaucoma possibly suggests HSV trabeculitis in the affected eye. It is difficult to ascertain this finding since we did not perform any investigation. A PCR assay for the detection of HSV DNA using aqueous humor would have provided supporting evidence.
This event was possibly a syndrome of HSV stromal and epithelial keratitis with trabeculitis, which explains the signs of a diffuse corneal stromal and epithelial edema and an acute rise in the intraocular pressure in the affected eye. The formation of epithelial bullae due to corneal edema could have predisposed the cornea for the development of dendritic ulcers. It has earlier been shown that the presence of corneal epithelial bullae has a statistically significant effect on the rate of ulcer development .
This case highlights the fact that HSK can present initially as a more diffuse corneal stromal and epithelial edema with epithelial bullae mimicking bullous keratopathy.
To the best of our knowledge and based on a MEDLINE search, such a presentation of HSK has not been documented.
Herpetic bullous keratitis, although unusual, should be considered in the differential diagnosis under such circumstances to prevent further complications and for the prompt institution of specific antiviral therapy.
We thank the patient for giving us informed consent to publish the details of the case.
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