Delayed-Onset Herpes Simplex Keratitis Masquerading As Persistent Epithelial Defect After Uneventful Phacoemulsification In An Immunocompromised Patient

To report a case of delayed-onset herpes simplex virus (HSV) keratitis presenting as a
persistent, treatment-resistant corneal epithelial defect following uncomplicated phacoemulsification
in a 65-year-old immunocompromised patient with diabetes mellitus, hypertension, and rheumatoid
arthritis. This case highlights the diagnostic challenge of atypical HSV reactivation in the setting of
postoperative topical corticosteroid escalation, where the classic dendritic morphology was absent,
and demonstrates the efficacy of combined oral valacyclovir and topical ganciclovir therapy in
achieving complete corneal healing and visual recovery.

Department of Ophthalmology, Recep Tayyip Erdoğan University, Faculty of Medicine,
Rize, Turkey. Tertiary referral center.

A 65-year-old patient with diabetes mellitus, hypertension, and rheumatoid
arthritis—but no prior herpetic history—underwent uneventful phacoemulsification with IOL
implantation for dense nuclear cataract (BCVA 20/200). Postoperative treatment included topical
moxifloxacin and dexamethasone/tobramycin. At day 10, the eye was quiet; the antibiotic was
stopped and the steroid was switched to dexamethasone 0.1% monotherapy. At day 17, the patient
presented with pain, photophobia, and decreased vision (BCVA 20/100). A 3.5 mm central epithelial
defect was identified; fluorescein staining showed no dendritic pattern. The patient was hospitalized
and treated with preservative-free artificial tears, autologous serum 20%, topical moxifloxacin, and a
bandage contact lens. After four weeks without improvement, re-evaluation revealed pseudodendritic
changes at the defect margins and markedly reduced corneal sensation. HSV keratitis was suspected.
Topical steroid was discontinued; oral valacyclovir 1000 mg TID and topical ganciclovir 0.15% gel
five times daily were initiated. Complete re-epithelialization was achieved within three weeks. Final
BCVA improved to 20/30 with no recurrence under prophylactic valacyclovir 500 mg daily.

HSV keratitis must be considered in the differential
diagnosis of persistent epithelial defects after cataract surgery, particularly in immunocompromised
patients and when topical corticosteroid potency has been escalated. Concurrent steroid use may mask
the classic dendritic pattern, delaying diagnosis. Combined systemic and topical antiviral therapy
achieved complete resolution in this case. Clinicians should maintain a high index of suspicion for
herpetic reactivation in patients with autoimmune disease or diabetes when standard supportive
wound-healing measures fail within two to three weeks postoperatively. Early antiviral intervention
prevents progression and preserves visual outcomes.