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Background: Microsporidial stromal keratitis poses several diagnostic challenges. Patients may present with corneal ulceration, marked stromal thinning, or even as a quite corneal scar. The presentation of microsporidial stromal keratitis commonly mimics viral keratitis. Microbiology scrapings are usually helpful; however, scraping and culture-negative cases pose a significant diagnostic dilemma. Histopathological examination is diagnostic but shows varying degree of inflammation, predominantly composed of polymorphonuclear leukocytes. Granulomatous inflammation, in microsporidial stromal keratitis, is never well described, and the authors in this article aim to describe the presence of granulomatous inflammation in microsporidial stromal keratitis, in patients with associated herpes simplex virus (HSV) keratitis., Methods: This was a retrospective and observational study conducted at a tertiary eye care center., Results: Of 263 patients who underwent therapeutic penetrating keratoplasty for infectious keratitis, during 2011-2013, seven patients were diagnosed as microsporidial stromal keratitis. Microsporidial spores could be demonstrated on microbiological scrapings in 5/7 (71%) of cases, but identified on histopathological examination and also confirmed on polymerase chain reaction (PCR) for microsporidium in 100% of cases. There was evidence of diffuse stromal necrosis with markedly severe degree of polymorphonuclear leukocytic infiltrates, with granulomatous inflammation in 42% of cases. Interestingly, these were positive for HSV-1 DNA on PCR. Review of medical records revealed much severe clinical presentations in patients with granulomatous inflammation, in comparison to cases without granulomatous inflammation., Conclusions: The authors hereby recommend that severe clinical presentation in patients with microsporidial stromal keratitis, markedly dense polymorphonuclear leukocytic infiltrates or the presence of granulomatous inflammation on the histopathological examination, should be investigated further for the presence of HSV-1 DNA for better patient management and good visual outcome.

A 76-year-old man presented with features of bilateral herpes simplex virus (HSV) keratitis. It was found to be recurrence of bilateral HSV keratitis following the use of Bimatoprost eye drops for uncontrolled intraocular pressure in a case of bilateral primary open-angle glaucoma.

Purpose: To record the natural history of herpes simplex keratitis and estimate visual impairment in eyes of patients diagnosed with herpes simplex keratitis., Materials: This was a retrospective, descriptive case study for five years of the eyes of patients with clinically diagnosed herpes simplex keratitis. These patients had presented to the cornea services and a cornea specialist carried out the ocular examination under slit-lamp magnification. The medical records were reviewed by the authors. Visual acuity at presentation and clinical details on examination were recorded and, diagnosis of the stage of disease given in the case record was noted. Statistical analysis was done using chi-square-test and Fisher exact test., Results: Of a total of 212 patients (220 eyes), there were 144 males and 68 females; 118 eyes presented with stromal lesions, 44 eyes with epithelial lesions, 39 eyes with epithelial and stromal lesions and 19 eyes with endothelitis. The improvement in visual acuity to more than 20/40 in the four clinical groups was 23 out of 44 eyes with epithelial lesion (52.27%), 83 out of the 118 eyes with stromal lesions (70.33%), 23 out of 39 eyes with epithelial and stromal lesions (58.97%) and 8 out of the 19 eyes with endothelitis (42.10%). The mean improvement in visual acuity was 3.44 lines (SD +/- 4.06)., Conclusion: Most patients had mild disease. The majority of the patients attained the final visual acuity of 6/12 or better in the affected eye. Thus, there was only a temporary visual morbidity with fairly good functional visual outcome in majority of the patients.

Chronic infection of the cornea by Herpes simplex virus (HSV) continues to be an important cause of unilateral blindness. Despite considerable progress in the understanding of the virus at cellular and molecular levels, the prospect of prevention still appears to be long way off. The development of non-toxic topical antiviral agents has been an important step forward in management. However, correct diagnosis and treatment, in particular, the avoidance of inappropriate use of topical steroid remains as important as ever. This article reviews the virological and clinical aspects of HSV keratitis including the current concepts of pathogenesis and management.