ESCRS - PO509 - Cross-Linking And Unanticipated Herpes Simplex Keratitis: Managing The Masquerader

Cross-Linking And Unanticipated Herpes Simplex Keratitis: Managing The Masquerader

Published 2025 - 43rd Congress of the ESCRS

Reference: PO509 | Type: Free paper | DOI: 10.82333/7g2e-8319

Authors: Vitor Menna Barreto 1 , Carlos Mascarenhas Menna Barreto 2 , Vicente Mascarenhas Menna Barreto 2 , Roberta Kern Menna Barreto* 2 , Pedro Kern Menna Barreto 2 , Fernanda Limeira Fanton 3

1Ophthalmology,Universidade de Caxias do Sul(UCS),Caxias do Sul,Brazil;Ophthalmology,Menna Barreto Eye Clinic,Porto Alegre,Brazil, 2Ophthalmology,Menna Barreto Eye Clinic,Porto Alegre,Brazil, 3Ophthalmology,Universidade de Caxias do Sul(UCS),Caxias do Sul,Brazil

Purpose

  • To investigate the development of atypical herpetic keratitis following corneal cross-linking (CXL) in a patient with no prior history of herpes simplex virus (HSV) infection.
  • To explore the potential role of topical anesthetic misuse (Alcaine) in precipitating corneal epithelial toxicity, delayed healing, viral activation, and subsequent infection.
  • To highlight diagnostic challenges and management strategies in distinguishing toxic keratopathy from infectious keratitis in post-CXL complications.

Setting

Universal Eye Hospital, Tirana, Albania

Methods

A 19-year-old male underwent the standard CXL with epithelium removal.

Right eye,previously almost non-symptomatic,showed poor epithelization. At first it showed a condition of superficial punctate keratitis and a small hazy area.Patient revealed he had used Alcaine drops almost every half hour which brought ocular surface toxicity.Three days after, the patient came with a painful swollen eye wider defect on superficial cornea and a ring infiltrate on the inferior periphery.A concern for an infectious etiology arose.Despite the rarity of microbial keratitis post-CXL, broad-spectrum antimicrobial therapy was initiated including aggressive topical and systemic antifungals and fortified antibiotics.Despite treatment, the condition deteriorated.

Results

Re-evaluation led to the suspicion of atypical HSV stromal keratitis.However, the rapid improvement following initiation of oral acyclovir (4 g/day) strongly supported HSV reactivation as the underlying cause.Complete epithelial healing was achieved within two weeks, and treatment was continued with oral antivirals, cautious steroid use (Loteprednol), and lubrication to promote corneal recovery.

After one month of antiviral therapy, corneal opacification significantly reduced, visual acuity improved, and the patient achieved clinical stabilization in the right eye.

Conclusions

The prolonged misuse of topical anesthetics can lead to severe corneal epithelial toxicity, delayed healing, and, in some cases, profound keratitis. This case underscores the importance of recognizing atypical HSV keratitis as a potential complication post-CXL, particularly in patients with unexplained non-healing epithelial defects. Misdiagnosis led to delayed treatment, highlighting the necessity of distinguishing between infectious and non-infectious causes of impaired corneal healing. While CXL remains a valuable treatment for keratoconus, clinicians must remain vigilant in assessing persistent epithelial defects to ensure accurate diagnosis and appropriate intervention, ultimately optimizing patient outcomes.