Resolvement Of Severe Keratitis With Use Of Intravenous Immunoglobulins

To report a case of IVIG treatment in severe stromal keratitis with hypopyon

Department of Ophthalmology, Clinical Hospital Center Rijeka

59-year-old patient with a history of well controlled HSV keratouveitis, presented with a 3 day history of blurred vision and eye redness.

Slit-lamp examination revealed an epithelial defect of almost the entire cornea, with stromal infiltrate with an endothelial plaque and 3-mm hypopyon. Visus at presentation was 4/20 with normal eye pressure. Corneal scrapings were taken for microbiological analysis, and empirical intensive systemic and topical fluoroquinolone along with acyclovir treatment was started. Additionally, due to previous history of prolonged corticosteroid treatment and clinical presentation, fortified voriconazole was introduced. After several days of treatment and findings of sterile corneal scrapings, we replaced acyclovir with valgancyclovir and introduced topical steroid treatment but with no effect. An aqueous humor sample was taken but was found to be negative for bacteria, fungi or viruses.

In further course, due to worsening of clinical presentation and with hypopyon progressed, we introduced human derived intravenous immunoglobulins (IVIG), 10g daily for 5 days.

The patient presented with significant improvement, showing healing of the epithelium, dissolvement of endothelial plaque and finally, resolution of hypopyion.

Systemic steroids were introduced and slowly tapered out over the weeks following the end of IVIG treatment with no recurrence noted.

Due to significant scarring patient underwent penetrating keratoplasty and is currently being followed up.

IVIG treatment exhibits immunomodulatory and anti-inflammatory effects along with IgG-guided antibacterial and antiviral activity, making it a suitable and safe second-line treatment in severe keratitis unresponsive to the standard-of-care treatment.