98 7 Three Atypical Cases of Thygeson’s Superfi cial Punctate Keratitis (TSPK)

Case 1: A Recurrence of an HSV Dendrite?

Case Report Day 1

A 51-year-old man was treated elsewhere with topical acyclovir for presumed HSV epithelial keratitis in the right eye. As the treatment had no e ect, adenovirus was suspected and treated with topical steroid with prompt e ect. A year and a half later, the symptoms recurred. Again, he was treated with acyclovir with no e ect. A week later, at presentation, both corneae showed many epithelial lesions, consistent with TSPK and rapidly resolving with topical steroid. A week after the treatment was started, he had no symptoms but both corneae still showed some rounded/abnormal cells spread over the surface and a few cysts. The patient was not seen thereafter. The photographs were taken at presentation (referred to as day 1) and a week later.

Fig. 7.1 Survey. Without staining, the cornea shows many grayish-whitish epithelial lesions (arrows) and light-reflecting abnormal cells (arrowheads) spread over the surface

Day 1

Fig. 7.2 (a) The lesions (arrows) stain yellow with (adherent) fluorescein and (b) red with rose bengal. In the in-between areas are visible many rounded/abnormal cells (arrowheads). Some areas showing rounded/abnormal cells are elevated (dark; bowed arrow). The area in frame in (b) is shown at higher magnification in Fig. 7.3 (opposite page). (b adapted from [1])

A Recurrence of an HSV Dendrite? (Case 1, cont.)

Day 1

Fig. 7.3 (a–d) Without staining are visible (a) the light-reflecting property and (b) the granular appearance of TSPK lesions (arrows); (a, b) additionally show rounded/abnormal cells (arrowheads) spread in the in-between areas. (c) Fluorescein reveals surface elevations (dark) and brightly green dots, and (d) rose bengal stains damaged surface cells/cell debris. With the slitlamp, the distribution of the lesions might give an impression of a branching figure. (The markers are placed in corresponding locations. Some other aspects of the area in frame in b are shown in Fig. 7.4, overleaf)

100 7 Three Atypical Cases of Thygeson’s Superfi cial Punctate Keratitis (TSPK)

A Recurrence of an HSV Dendrite? (Case 1, cont.)

Fig. 7.4 (a–d) The area in frame in Fig. 7.3. Visible are: (a–c) many rounded/abnormal cells (arrowheads) giving the lesion (arrow) its granular appearance, (c, d) red rose bengal staining of damaged surface cells/cell debris, and (d) circumscript green fluorescein staining. The lesion has indistinct edges, and rounded/abnormal cells are present also in the surroundings. (The markers are placed in corresponding locations)

A Recurrence of an HSV Dendrite? (Case 1, cont.) 101

A Recurrence of an HSV Dendrite? (Case 1, cont.)

a

Day 1

Fig. 7.6 (a–c) Different areas showing lesions (arrows) and individual rounded/abnormal cells (white arrowheads) spread over the surface. (b and c) show rose bengal staining of the lesions and the absence of red staining in the in-between areas. In (c) are visible rounded cysts containing rounded cells (black arrowheads)