Author: Shiao Wei Wong (United Kingdom)
Co-authors: Peter Garside, Felipe Dhawahir-Scala, Nicholas P Jones, Laura R Steeples, Sasa Pockar
Purpose
To describe the clinical presentation and management of bilateral non-simultaneous severe herpes simplex virus 2 (HSV-2) panophthalmitis causing severe vision loss in a young immunocompetent patient.
Setting/Venue
Manchester Royal Eye Hospital, United Kingdom.
Methods
A case report of a 22-year-old immunocompetent male with a history of previous right eye severe HSV2-panophthalmitis. He presented with a two-week history of left painful eye, periorbital swelling and vision loss. The right eye had presented with panophthalmitis, including total retinal necrosis, retinal detachment, marked scleritis five years previously and had become blind and phthisical. He was lost to follow-up. The left eye was normal at last the follow-up. The patient had a history of substance abuse and learning difficulties. We also present imaging findings, including intra-operative images, ultrasound images and computerised tomography (CT) findings.
Results
On examination, he had left severe periocular oedema, complete ophthalmoplegia, proptosis, chemosis, intraocular pressure of 35mmHg and no perception of light vision in both eyes. There were granulomatous keratic precipitates, fibrin and 3+cells in the left anterior chamber. There was no fundal view, and ultrasound demonstrated vitritis, extensive serous detachments and scleral thickening. A CT orbit showed diffuse fat-stranding and scleral thickening but no collection. The vitreous tap was HSV2 polymerase chain reaction (PCR) positive. He received intravitreal Foscarnet (2.4mg/0.1ml) and was commenced on high-dose intravenous aciclovir and subsequently high-dose systemic corticosteroid. VA improved to perception of light following treatment; however, the eye became hypotonous without a fundal view. He underwent pars plana vitrectomy with silicone oil tamponade. Dense vitreous debris with 360° retinal necrosis, extensive occlusive vasculitis involving the posterior pole and pale optic nerve were observed. The panophthalmitis settled with final visual acuity of 6/48 at 1meter at 2 months.
Conlusions
Panophthalmitis is a rare and extremely severe presentation of HSV intraocular infection, which can initially go unrecognised, leading to late diagnosis and poor outcome. To our knowledge, this is the first reported case of bilateral non-simultaneous HSV2-associated panophthalmitis. Prompt diagnosis with PCR vitreous tap and treatment with high dose systemic aciclovir and corticosteroid followed by vitrectomy led to improved orbital and ocular inflammation. Investigations for immunodeficiency, including specific susceptibility to HSV infection (HLA DQ7 and TLR-4), are recommended. HLADQ7 was negative in our patient. Patients with a history of HSV retinal necrosis are at risk of second eye involvement, months or years after the first eye presentation. A high index of suspicion of an infectious agent as aetiology with a low threshold for vitreous sampling is warranted in severe cases of panophthalmitis.
Financial Disclosure
No financial interest
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