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    HHV-1, -2, -3: Precise medical management of herpetic nodular anterior scleritis

     

    Conclusion

    This case demonstrates many important points about the presentation, evaluation, and management of patients with nodular anterior scleritis. Examination of the superior sclera with a muscle light and lid elevation can help with proper diagnosis. The presence of transillumination defects of the iris in the setting of ocular inflammation should raise clinical suspicion of a herpetic cause.

    Utility of serologic testing can be limiting or even misleading, and in the right clinical context (such as previously failed targeted treatment), may warrant a more precise diagnostic approach (such as aqueous biopsy with PCR testing).

    Careful discretion of steroid drops should be considered with regard to risk of IOP elevation.

    Finally, this case also highlights that misdiagnosis may perpetuate disease by promoting HHV replication in the setting of immunosuppression without concomitant anti-herpetic viral suppression.

     

    References

     

    1.    Berchicii L, Miserocchi E, Di Nicola M, La Spina C, Bandello F, Modorati G. Clinical features of patients with episcleritis and scleritis in an Italian tertiary care center. Eur J Ophthalmol. 2014;24:293-298.

    2.    Slabaugh MA, Herlihy E, Ongchin S, van Gelder RN. Efficacy and potential complications of difluprednate use for pediatric uveitis. Am J Ophthalmol. 2012;153:932-938.

    3.   Jaaskelainen AJ, Viitala SM, Kurkela S, Hepojoki S, Sillanpaa H, Kallio-Kokko H, Bergstrom T,Suni J, Narvanen A, Vapalahti, Vaheri A. Performance of a multiplexed serological microarray for the detection of antibodies against central nervous system pathogens. J Microbiol Methods. 2014;100:27-31.

    4.   Barequet IS, Li Q, Wang Y, O’Brien TP, Hooks JJ, Stark WJ. Herpes simplex virus DNA identification from aqueous fluid in Fuchs heterochromic iridocyclitis. Am J Ophthalmol. 2000;129:672-673.

    5.   Loureiro M, Rothwell R, Fonseca S. Nodular scleritis associated with herpes zoster virus: an infectious and immune-mediated process. Case Rep Ophthalmol Med. 2016;2016:8519394 doi: 10.1155/2016/8519394. Epub 2016 May 19.

    6.   Gonzalez-Gonzalez LA, Molina-Prat N, Doctor P, Tauber J, Sainz de la Maza MT, Foster CS. Clinical features and presentation of infectious scleritis from herpes viruses: a report of 35 cases. Ophthalmology. 2012;119:1460-1464.

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