Material and Methods

A 50 year old man presented with pain, redness, dimunition of vision in his left eye since 2 months. He had no history of trauma, foreign body fall into the eye. He was treated elsewhere with antifungal (Natamycin eye drops hourly), antibacterial (Moxifloxacin 0.5% eye drops hourly) and cycloplegic (atropine eye drops 2 times) in a day for 2 month with no response. At presentation he presented with visual acuity of 20/25 in right eye, hand movements in left eye. Anterior & posterior segment were normal in right eye. His left eye showed diffuse conjunctival congestion, central corneal epithelial defect (1.2 x 4.2 mm) with anterior to midstromal infiltrate (1x 2 mm) with surrounding stromal edema, scarring all around (Figure 1). Anterior chamber showed flare, cells and trace hypopyon. Posterior segment was within normal limits. Corneal scraping was done for bacteria and fungus which yielded no organisms. IFA, PCR for HSV 1 was also negative. Confocal microscopy also was inconclusive. Patient was started on fortified cefazolin and ciprofloxacin eye drops hourly with atropine eye drops 3 times day for 4 days. After 4 days there was no response and a repeat corneal scraping was done which showed gram negative coccobacilli, identified as Acinetobacter on culture. It was sensitive to most of the antibiotics except cefuroxime and chloramphenicol. Two weeks on intensive antibiotics did not yield any response. Patient was seen regularly for three months with no response. His visual acuity was the same and also the clinical picture. After three months the diagnosis was revised, as he had chronic presentation, stromal edema, scarring all around with few deep vascularizations, herpes simplex virus stromal keratitis was suspected and he was started on Acyclovir eye ointment 5 times a day and Prednisolone acetate eye drops 8 times a day. He was seen after one week with a dramatic improvement. His visual acuity improved to 20/150 with resolution of infiltrate, stromal edema. Later he was continued on tapering dose of Prednisolone acetate eye drops with Acyclovir eye ointment for 1 week more. After one month he had a best corrected visual acuity of 20/60 with complete resolution of infiltrate, stromal edema with some amount of stromal scarring (Figure 2).

Figure 1: Case 1 at the time of presentation showing inflamed eye with corneal infiltrate and hypopyon.

Figure 2: Case 1 after starting antiviral and steroid therapy showing a quite eye with corneal scar.

The second case also presented with similar clinical history andfindings which responded with antiviral and steroid therapy insteadof antibacterial therapy (Figures 3 and 4).

Figure 3: Case 2 showing inflamed eye with central corneal ulcer.

Figure 4: Case 2 after starting antiviral and steroid therapy showing a quite eye with corneal scar.