Answers

1. [Figure 1]: Herpetic necrotizing stromal keratitis. (a) slit-lamp exploration: Stromal disciform infiltrate (orange dashed circle), granulomatous keratic precipitates under the edematous lesion (some marked with an orange arrowhead), melting and corneal descemetocele (orange star) (b) ASOCT: Anterior chamber reaction (hyperreflective points inside the anterior chamber, blue dashed line) and descemetocele formation (orange star)
2. [Figure 2]: Herpetic dendritic epithelial lesion (orange arrowhead) over a preexisting corneal descemetocele (orange star) in the context of a likely necrotizing stromal keratitis incipient relapse (orange dashed circle). (a) slit-lamp exploration; (b) ASOCT
3. Topical corticosteroids and oral antiviral at therapeutic dosage. Bacterial keratitis should always be covered. If keratolysis is a prominent feature, bondage might be placed
4. A necrotizing stromal keratitis with a rapid development descemetocele should always be considered for a penetrating keratoplasty.

Discussion

Herpetic eye disease is the leading cause of infectious blindness in developed countries.^[1]

It can involve any layer of the cornea, the harmful mechanism being a mixture between direct viral injury and autoimmune processes. In necrotizing stromal keratitis, direct viral activity is considered to be the main tissular aggressor.

Clinically, it is presented as stromal keratitis with epithelial ulceration. Keratolysis is of great concern. Melting can rapidly lead to descemetocele formation or corneal perforation. It can also involve granulomatous keratic precipitates and anterior chamber reaction. Limbal insufficiency, scarring, and lipid deposition can ensue.^[2]

The diagnosis, as with the rest of stromal keratitis, is mainly clinical.

The recommended treatment regime is topical prednisolone acetate 1% one to four times daily and an oral antiviral at a therapeutic dosage. In this case, valacyclovir 1 g three times daily was used. Bacterial and fungal keratitis must be considered, and bacterial keratitis must be empirically covered until the microbiological results are given.^[2],[3] Herein, microbiological samples were taken, fulminant presentation by other microbial agents was ruled out, and herpetic etiology was confirmed.

In the case of severe sequelae or impending perforation, penetrating keratoplasty should be performed. This being so in the presented case.

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