1. 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

2. 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

3. 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

4. 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

5. 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

6. 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 yrs)
Mean duration of treatment /-8.7 days
Cornea & Ocular Trauma Services, Retina Foundation, Ahmedabad

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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