EFFICACY OF COMBINED THERAPY OF FINE NEEDLE-DIATHERMY WITH INTRASTROMAL AND SUBCONJUNCTIVAL BEVACIZUMAB FOR A STRIKING HERPETIC COMPLICATION

To report the management with anatomical and functional recovery of a case with corneal scarring and neovascularization after herpetic keratitis with a one-year follow-up.

Hospital Universitario Virgen de la Victoria, Málaga. Spain.

A 60-year-old male presented to our emergency department with severe pain, redness and unilateral loss of vision for several days before. Slit-lamp examination and fluorescein staining reveled a paracentral geographic epithelial keratitis with a peripheral area of dendritic pattern and terminal bulbs. He had history of type 2 diabetes, high blood pressure and moderate alcohol consumption. No topical steroids or other treatments were previously used. Oral valacyclovir and topical ganciclovir combined with cycloplegic drops and topical antibiotics allowed the re-epithelization with a significant residual leucoma. Three months later, the patient developed a recurrence as a marginal herpes simplex keratitis which was solved with antiviral treatment, but causing a significant corneal scarring increase with stromal thinning. 

He remained stable with no more recurring herpes outbreaks until one year after the symptom’s onset, when he showed the previous stromal opacity covered by a large corneal vessel complex (5.0 x 3.0 mm) with active aspect, very close to the visual axis.

The patient was planned for fine-needle diathermy to occlude the main feeder vessel. It was performed by topical anesthesia, using a 10/0 nylon suture needle with a diathermy setting of 1 mA. The cauterization lasted until the blanching of the vessel was appreciated. Immediately thereafter, intrastromal and subconjunctival 5 mg/0.2 ml bevacizumab injection was done. We used a 30G needle to inject the solution in the stromal area of the larger feeder vessel and in the surrounding conjunctiva. This treatment was complemented with topical steroids in a descending regimen. After four weeks, there was a drastic regression of the previously corneal neovascularization. Subsequently, disappearance of the corneal opacity occurred to a great extent, showing stability over the next 12 months.

Herpes keratitis can lead to a devastating pathological process which involves the breakdown of the limbal barrier and the formation of blood vessels, leading to a severe corneal transparency impairment. The unique cycle combination therapy we describe in this report was successful to manage this challenging complication.  It showed no adverse local or systemic adverse reaction, achieving a good anatomical and functional result.