Patients’ noncompliance with prescribed treatment protocols is an unfortunate reality in medicine, and the reasons for this noncompliance are often multifactorial. Here, I present a case of a 36-year-old female with no known comorbidities who has experienced a 7-year history of intermittent redness in her left eye associated with blurring of vision. She was previously diagnosed with herpes simplex virus (HSV) stromal keratitis; however, due to financial constraints, she was noncompliant with medications and follow-up consultations. This led to the development of a large corneal ulcer, which caused unbearable foreign body sensation and photophobia, prompting her to seek consultation at our outpatient clinic.
Presentation
A 36-year-old female presented to our outpatient clinic seeking a second opinion regarding her left eye. Seven years prior, she experienced sudden onset of eye pain associated with eye redness and blurred vision. She then noted a central whitish opacity which prompted an initial consult with a private ophthalmologist, who diagnosed her with HSV stromal keratitis. The patient was prescribed steroid and antibiotic eye drops, atropine sulfate drops, and acyclovir eye ointment. However, due to financial constraints, she was unable to adhere to her medication regimen, nor keep up with her follow-up schedule.
Two years earlier, she noticed increasing size of the corneal opacity, with progression of the blurring of vision in the same eye, as well as increasing foreign body sensation and photophobia. She admitted self-medicating with antibiotic and steroid drops for intermittent eye redness, which would partially improve her symptoms. About 2 weeks prior to her visit to our clinic, the patient had another episode of eye redness with unbearable eye pain and photophobia. Persistence of these symptoms prompted her to consult with her previous ophthalmologist 4 days prior, where she was prescribed topical levofloxacin 0.5%, atropine sulfate drops, ganciclovir gel, and oral acyclovir 400mg/tab 5 times daily. However, non-resolution of her symptoms prompted her to seek a second opinion at our clinic.
At the time of her visit, her visual acuity on the affected eye had become so severe that she was only able to see hand movement with good light projection. No reverse relative afferent pupillary defect was noted and intraocular pressures were normal. Corneal sensitivity testing showed 100% sensitivity OD, but only 50% OS. Slit-lamp evaluation of the left eye showed hyperemic conjunctiva, and a large, central, deep ulcer with irregular, thickened, grayish, heaped up borders, with surrounding stromal haze that measured around 5.5 x 5.0 mm. The edges of the ulcer stained weakly with fluorescein, and there were multiple superficial and deep stromal neovascularizations inferiorly (Figure 1). The anterior chamber was deep with limited view of the other structures due to the corneal haziness, and cells and flare could not be assessed. She was thus diagnosed with neurotrophic keratopathy or metaherpetic ulcer from recurrent herpes simplex keratitis of the left eye.
Figure 1. Left eye with hyperemic conjunctiva and a large, central, deep corneal ulcer with irregular, thickened, grayish, heaped up borders with weak fluorescein staining, and corneal neovascularization inferiorly.
Treatment
Debridement of the ulcer edges was done with application of a bandage contact lens. Copious lubrication with preservative-free sodium hyaluronate drops was advised to promote epithelial healing. She was also prescribed topical levofloxacin 0.5% drops for antibiotic prophylaxis, atropine sulfate drops to reduce ciliary spasm and eye pain, and oral acyclovir 400 mg/tab BID. Her subsequent follow-up appointments showed significant improvement in the epithelial healing, as well as a meaningful reduction in eye pain and foreign body sensation, although with a concomitant central corneal scarring (Figure 2).
Figure 2. Follow-up visit showed improvement in epithelial healing with substantial corneal scarring.
Summary and Discussion
Neurotrophic keratopathy (NK) arises from impaired corneal innervation in combination with decreased tear secretion as a sequelae to recurrent HSV infection.1 It can be classified into three stages according to the Mackie classification: stage 1 is characterized by epithelial changes, stage 2 with persistent epithelial defects, and stage 3 with corneal ulcer associated with progressive stromal melting.2 This case displayed findings typical in advanced neurotrophic keratopathy, like an irregular ulcer with thickened, heaped-up borders. Unlike the other forms of herpetic keratitis, there is no viral reactivation in NK, hence, this may be exacerbated by chronic use of topical medications like antivirals and preservative-containing eye drops. Once an ulcer has been identified as neurotrophic, treatment must be geared toward decreasing exposure of the cornea to toxic substances, especially topical antivirals, while increasing lubrication to facilitate epithelial healing using preservative-free artificial tears or autologous serum eye drops.1-4
Without appropriate diagnosis and treatment, this patient could have faced more serious complications, such as corneal perforation due to progressive thinning of the central cornea. Therefore, it is crucial to educate our patients about the potential outcomes of noncompliance to treatment. In this case, we were able to facilitate the corneal healing process and avert possible perforation. However, the patient is still left with a large central scar that will limit her vision, and which will ultimately require a corneal transplant for visual rehabilitation.
1. Mannis MJ, Holland EJ. Cornea. 5th ed. Elsevier; 2022.
2. Feroze KB, Patel BC. Neurotrophic Keratitis. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431106/
3. Nowińska, A. Chapter 2: Recent Advances in the Diagnosis and Management of Herpetic Keratitis. In: Rodriguez-Garcia A and Hernandez-Camarena JC, eds. Infectious Eye Diseases – Recent Advances in Diagnosis and Treatment. IntechOpen. Available at https://www.intechopen.com/books/10345; accessed October 11, 2024.
4. Sacchetti M, Lambiase A. Diagnosis and management of neurotrophic keratitis. Clin Ophthalmol. 2014;8:571-579.
