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Year : 2022  |  Volume : 15  |  Issue : 3  |  Page : 360-362  

Presumed herpes simplex virus ulcerative nodular episcleritis treated by topical acyclovir alone

1 Department of Ophthalmology, Apollo Hospitals, Navi Mumbai, Maharashtra, India
2 Eyemax Superspeciality Eye Center, Navi Mumbai, Maharashtra, India

Date of Submission02-May-2021
Date of Decision24-May-2021
Date of Acceptance26-Aug-2021
Date of Web Publication02-Nov-2022

Correspondence Address:
Abhishek Hoshing
Department of Ophthalmology, Apollo Hospitals, Plot No. 13, Parsik Hill Road, Sector 23, CBD Belapur, Navi Mumbai - 400 614, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ojo.ojo_138_21

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A 7-year-old female child was referred to the cornea clinic with a painless, ulcerated, and inflamed nodule near the limbus which did not respond to 1-week antibiotic therapy and worsened on starting topical steroids. Clinical examination showed ulcerative nodular episcleritis and raised a suspicion of herpes simplex virus etiology. The patient responded well and resolved completely on topical antiviral therapy alone.

Keywords: Episcleritis, herpes simplex virus, limbal nodule

How to cite this article:
Hoshing A, Seth A, Subramaniam A. Presumed herpes simplex virus ulcerative nodular episcleritis treated by topical acyclovir alone. Oman J Ophthalmol 2022;15:360-2

How to cite this URL:
Hoshing A, Seth A, Subramaniam A. Presumed herpes simplex virus ulcerative nodular episcleritis treated by topical acyclovir alone. Oman J Ophthalmol [serial online] 2022 [cited 2023 Feb 8];15:360-2. Available from: https://www.ojoonline.org/text.asp?2022/15/3/360/360393

   Introduction Top

Keratitis and uveitis secondary to herpes simplex virus (HSV) infections have been the main area of focus for ophthalmologists.[1] In this report, we present a unique case of presumed HSV ulcerative nodular episcleritis which was treated with topical acyclovir eye ointment alone.

   Case Report Top

A 7-year-old girl was referred to the cornea clinic for evaluation of a painless, red, nodular swelling present in the outer aspect of the left eye for 8 days. At the initial consultation, a pediatrician prescribed moxifloxacin 0.5% drops four times/day for 1 week. After 1 week, as no improvement was noted, a combination drop containing tobramycin 0.3% and loteprednol 0.1% four times/day was also added by him. However, within a day of this, the nodule increased in size and inflammation.

There was no history of trauma to the eye or discharge/bleeding from the nodule. There was no past history of similar complaints.

On examination, uncorrected visual acuity (UCVA) in both eyes was 6/6 N6. The right eye was normal. In the left eye, the lids and adnexa were normal. There was a nodule near 3 o'clock limbus measuring approximately 3 mm × 2.5 mm × 0.5 mm with congestion and dilatation of the surrounding episcleral and conjunctival vessels. The conjunctiva covering the nodule appeared ulcerated which was confirmed by fluorescein staining. There was a thin layer of mucous coating on the floor of the ulcer but no visible pus point, internal vascularity, or keratinization [Figure 1]. The nodule was not tender and was freely mobile over the underlying sclera.
Figure 1: Slit-lamp image in diffuse illumination (a) and with cobalt blue filter (b) demonstrating the clinical signs at presentation. (Star mark in b denotes the fluorescein stained conjunctival ulcer)

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Absence of history of trauma and pus point and nonresponsiveness to topical antibiotics reduced the probability of a bacterial infection. Worsening of the lesion on topical steroids and presence of ulceration on the overlying conjunctiva ruled out a purely inflammatory/autoimmune pathology. The conjunctival ulcer resembled a geographic ulcer seen in HSV epithelial keratitis.

Based on this clinical suspicion; she was prescribed acyclovir 3% ointment five times/day and was asked to continue moxifloxacin 0.5% drops four times/day. Tobramycin and loteprednol combination drops were discontinued and review was scheduled after 2 days. We planned to scrape the ulcerated nodule if no improvements were noted on follow-up.

Within 2 days, the episcleral congestion had reduced to 2 mm × 2 mm × 0.5 mm. The ulceration of the overlying conjunctiva had reduced too [Figure 2]. The child was advised to continue the same treatment and follow-up after 3 days.
Figure 2: Slit-lamp image, on day 3, in diffuse illumination (a) and with cobalt blue filter (b) showing reduction in the size and inflammation of the nodule and the size of conjunctival ulceration (Star mark in b denotes the fluorescein stained conjunctival ulcer)

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On day 5, there was a marked reduction in the congestion and dilatation of vessels. The nodule had further reduced in size and the conjunctival ulcer had healed [Figure 3]a. The child was advised to continue acyclovir ointment for 10 more days (total: 15 days). Moxifloxacin drops were discontinued.
Figure 3: Slit-lamp image in diffuse illumination of day 5 (a) and day 10 (b) showing progressive resolution of the nodular episcleritis. (b) Pigmentation and increased vascularization after complete resolution of the nodule

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Ten days later (day 15 of therapy), there was complete resolution of the episcleral nodule. The conjunctival ulcer had completely healed with localized pigmentation and vascularization [Figure 3]b. At this visit, fluorometholone 0.1% drops were started four times/day with an instruction to taper by one time after every week. This was done to minimize pigmentation and vascularization within the palpebral aperture. The patient was advised to continue acyclovir ointment for 1 more week and to follow-up after 1 month.

At 1 month, the child was asymptomatic. The localized pigmentation and vascularization of the conjunctiva persisted. UCVA was 6/6 N6 and intraocular pressures were normal in both eyes. She was advised to discontinue fluorometholone 0.1% drops and follow-up as required.

   Discussion Top

Episcleritis, as a presentation of HSV infection of the eye, has been rarely reported in literature. Radia et al. report a case of recurrent “presumed” HSV keratitis and bilateral episcleritis in a 47-year-old patient with keratosis follicularis who was treated with simultaneous topical acyclovir and ofloxacin along with systemic acyclovir and flucloxacillin.[2] Our patient had no predisposing conditions, had uniocular involvement, and presented with a localized inflamed nodule with ulceration of the overlying conjunctiva which resembled a geographic ulcer. This typical ulcer raised the suspicion of HSV etiology and prompted topical antiviral therapy. The quick response to treatment reinforces the “presumed” HSV etiology.

Our patient did not respond to topical antibiotics, worsened on adding topical steroids, improved rapidly with topical antiviral therapy, and did not require systemic antiviral treatment. To the best of our knowledge, this is the first report of this unique presentation and treatment outcome.

Episcleritis can be a manifestation in approximately 30% of patients of herpes zoster ophthalmicus (HZO), but the nodular variant is the least common of them all.[3] Our patient neither had a history of chickenpox nor associated symptoms of HZO. Furthermore, in a study conducted by Marsh and Cooper, it was demonstrated that acyclovir ointment alone is insufficient to treat episcleritis secondary to HZO and a combination of acyclovir ointment and topical steroids is arguably better.[4] This is in direct contradiction to observations from our case, and hence, we rule out varicella zoster virus as the etiology.

The fact that the episcleritis initially worsened on starting steroid-containing drops and resolved completely with topical acyclovir indicates that it was a direct infection of the episcleral tissue and not an immune-mediated/inflammatory response. Worsening of the episcleritis on steroids may be analogous to worsening of HSV dendritic ulcers of the cornea to geographic ulcers if wrongly treated with topical steroids.

In conclusion, ulcerative nodular episcleritis is probably a rare presentation of HSV infection. Direct infection of the episcleral tissue seems to be the underlying mechanism, and hence, it responds well to topical acyclovir therapy. Standard histopathological or immunofluorescence studies done on samples acquired from such lesions may help to establish HSV as the etiology. We should remember that HSV infection is a differential diagnosis in ulcerative nodular episcleritis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given her consent for images and other clinical information to be reported in the journal. The guardian understands that her names and initials will not be published and due efforts will be made to conceal the patient's identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Green LK, Pavan-Langston D. Herpes simplex ocular inflammatory disease. Int Ophthalmol Clin 2006;46:27-37.  Back to cited text no. 1
Radia M, Gilhooley MJ, Panos C, Claoué C. Recurrent presumed herpes simplex keratitis and episcleritis in keratosis follicularis (Darier's disease). BMJ Case Rep 2015;2015:bcr2015210772.  Back to cited text no. 2
Nigam P, Kumar A, Kapoor KK, Sarkari NB, Gupta AK, Lal BB, et al. Clinical profile of herpes zoster ophthalmicus. J Indian Med Assoc 1991;89:117-9.  Back to cited text no. 3
Marsh RJ, Cooper M. Double-masked trial of topical acyclovir and steroids in the treatment of herpes zoster ocular inflammation. Br J Ophthalmol 1991;75:542-6.  Back to cited text no. 4


  [Figure 1], [Figure 2], [Figure 3]


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