Bilateral Diffuse Herpetic Endotheliitis Clinical Features

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Bilateral Diffuse Herpetic Endotheliitis
Clinical Features Role of Laboratory
Diagnosis in Management
Dr. Manoj Sharma, MD Radhika Tandon, MD, DNB,
FRCS, FRCOphth Dr Gita Satpathy, MD
Department of Cornea, Cataract Refractive
Surgery and Ocular Microbiology Dr Rajendra
Prasad Centre For Ophthalmic Sciences, AIIMS
The authors have no financial interest in the
subject matter of this poster
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Aim

• To report the clinical features and management
• outcome in two patients with
• bilateral diffuse herpetic endotheliitis

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Clinical Presentation

• Two patients presented with
• acute onset
• bilateral
• diminution of vision
• ocular pain, redness, and photophobia
• Case 1 65-year-old male with vision of 6/36 (OU)
• Case 2 55-year-old male with vision of 1/60 (OU)
  past history of keratitis in one eye (OS)

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Slit Lamp Examination
Case 1
2a
1a
2b
1b

• Bilateral
• Circumcorneal congestion, diffuse stromal oedema,
  Descemet folds, keratitic precipitates and
  anterior chamber reaction
• Reduced corneal sensations
• Normal IOP

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Slit Lamp Examination
Case 2

• Bilateral
• Circumcorneal congestion, diffuse stromal oedema,
  Descemet folds, keratitic precipitates and
  anterior chamber reaction
• Reduced corneal sensations
• Normal IOP
• Left eye had an additional superficial opacity
  (arrow)

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Laboratory Diagnosis

• Tear samples from case 1 were negative and case 2
  positive for HSV DNA in both eyes
• Complete resolution of inflammation and oedema
  occurred in both cases with treatment

1 2 3 4 M 5 6 7
Lane 1-4 Clinical samples Lane M 100 bp DNA
ladder Lane 5 Clinical sample Lane 6
Positive control Lane 7 Negative control
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Case 2
Case 1
Clinical Photographs of both patients after 12
month follow up

• Oral acyclovir was continued for 6 mths to
  prevent recurrence
• No recurrence was noted during 12 months
  follow-up
• Patients regained vision maintained BCVA at 12
  months
• 6/6 (OU) case 1
• 6/6(OD) and 6/9 (OS) case 2

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Laboratory Diagnosis

• Before starting treatment tear samples from both
  eyes of patients were collected by fire polished
  microcapillary tube and subjected to PCR for HSV
  DNA detection
• PCR Protocol
• DNA extraction commercial QI Amp DNA blood kit
• Polymerase chain reaction
• Primer-111 bp region of HSV 1 thymidine kinase
  gene (Hofgartner W T et. al Clinical chemistry,
  1999) Amplification- thermal cycler
• (Gene Amp PCR system 9700, applied biosystem,
  USA)
• Electrophoreses- in 2 agarose gel

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Treatment

• Tab acyclovir 400 mg (5 times/day) 7 days
• Tab acyclovir 400 mg (BD) 6 months
• Topical steroid (1 prednisolone acetate)
• Adjunct therapy was given as required
• Topical antibiotic
• Topical mydriatic (2 homatropine)
• Topical lubricant (preservative free)
• Analgesics (if required)

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Conclusion

• HSV-1 may cause bilateral diffuse corneal
  endotheliitis, Therefore it should be regarded
  as a manifestation of HSV 1 corneal infection
• High index of suspicion is required in such cases
  and patients treated appropriately
• PCR in tear samples may be helpful and serve as
  a
• non invasive diagnostic tool in some cases

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Address for Correspondence

• Dr Radhika Tandon
• Professor of Ophthalmology
• radhika_tan_at_yahoo.com
• Dr. RP Centre for Ophthalmic Sciences, AIIMS
• New Delhi 110029
• India