Myasthenia Gravis And Herpetic Keratitis.

Management of herpetic keratitis in patient with myasthenia gravis (MG).Case report.

Clinic N19,Ophthalmology department,Yerevan,Armenia

The case report describes a 71-year-old female with a known history of ocular myasthenia gravis who presented with pain in her right eye, photophobia, tearing, conjunctival injection and blurred vision persisting for the last 20 days. The patient has been on a high dose of methylprednisolone (28mg per day) for the past 3 months.

The patient's SL examination revealed a geographic epithelial defect and underlying mild stromal edema. A positive PCR test for HSV confirmed the diagnosis of HSV geographic keratitis, and treatment commenced with both topical and systemic antiviral medications.One year after the initial episode of herpetic geographic ulcer, the patient presented with mild eye pain, blurry vision, and herpes labialis. Additionally, the patient was on a reduced dosage of systemic steroids (methylprednisolone 4 mg per day). A slit-lamp examination revealed herpetic disciform keratitis, and treatment was started with both topical steroids and systemic antiviral medications.

Treatment with high doses of systemic corticosteroids (such as methylprednisolone) in patients with MG may induce immunosuppression, potentially leading to HSV reactivation and various presentations of Herpetic eye diseases.
Patients with epithelial or disciform keratitis taking systemic corticosteroids for other indications should be treated with systemic antiviral therapy.
For MG patients with recurrent HSV keratitis on systemic corticosteroids, lifelong antiviral prophylaxis is advised to prevent further reactivation of  Herpetic eye  disease.
Close coordination between a neurologist managing the MG and an ophthalmologist managing the herpetic eye disease is crucial.