In vivo confocal microscopy in bilateral herpetic keratitis: a case report

Bilateral herpetic keratitis is a rare infection of the cornea. Ocular herpes in atopic patients is more often bilateral, with more frequent recurrences. The authors report a case of bilateral herpes simplex virus (HSV) keratitis during the active phase studied by in vivo confocal microscopy. A 28-year-old man with 5 years history of unilateral HSV keratitis and atopic dermatitis was referred to the authors for a clinical and diagnostic evaluation.RESULTS. The corneas showed the typical features of dendritic HSV keratitis in both eyes. Examination by in vivo confocal microscopy demonstrated similar lesions in both eyes: a distortion of the superficial and basal epithelium and the presence of irregular hyperreflective structures and dendritic particles near the epithelial cells. The subbasal nerve plexus presented a tortuous appearance with hyperreflective areas and beadlike formations along the fibers. After a week of antiviral treatment, in vivo confocal microscopy examination demonstrated an irregular epithelium with highly reflective deposits and reflective areas. A reduction of nerve fiber bundles with a large number of beadlike formations and abnormal tortuosity was also noted. In vivo confocal microscopy enables a noninvasive evaluation of the ocular surface at a high magnification level. It could be useful for the early and differential diagnosis of corneal infections and when HSV keratitis recurrence is suspected.