Difficulties In The Management Of Herpetic Keratouveitis: A Case Report

Herpetic viral keratouveitis is characterized by keratitis, anterior segment inflammation, elevated intraocular pressure (IOP) and iris atrophy. 

This case demonstrates an unusual presentation of Herpes simplex virus (HSV) ocular infection and the challenges faced during the management of its complications.

A seventy-two year old man presented to us with complaints of pain and tearing in his right eye for a month. There was no history of ocular trauma. He has had several similar episodes over the past few years, suffering from HSV keratouveitis, was referred for non-response to treatment with the prophylactic dose of oral acyclovir and acetazolamide.

He had large epithelial bullae, anterior chamber reaction, and increased intraocular pressure in his right eye. Initially, he responded to the therapeutic dose of oral acyclovir, but he developed elevated intraocular pressures up to 38 mmHg on maximal medical therapy

Therefore, trabeculectomy with mitomycin-C a was considered. He also developed corneal endothelial decompensation, for which automated endothelial keratoplasty by Descemet stripping (DSAEK) could also be proposed.

HSV keratouveitis is associated with anterior chamber inflammation, endothelitis, and increased intraocular pressure.

A combination of antiviral, anti-inflammatory and anti-glaucoma medical treatments helps in management. However, glaucoma filtration surgery is often necessary to control intraocular pressure.

Chronic recurrent episodes ultimately lead to endothelial failure and require endothelial keratoplasty (EK) or sometimes full-thickness keratoplasty.

This case highlights the difficulties in treating HSV-related keratouveitis with glaucoma refractory to topical medical treatment and corneal decompensation responsible for the loss of vision.

Surgical treatment in this case remains the only therapeutic alternative,