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Make a long case presentation of this case history of 70 yr old female bhuriya, presented with le pain dimnision of vision with thinning and associated with herpetic eye disease

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herpes simplex keratitis

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herpes simplex keratitis corneal thinning management American Academy of Ophthalmology

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PMID: 37184084

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https://www.aao.org/education/clinical-statement/herpes-simp…

Long Case Presentation

Identification Data

Name: Mrs. Bhuriya
Age/Sex: 70-year-old female
Eye affected: Left eye
Date of presentation: [Insert]
Informant: Patient/relative
Reliability of history: [Reliable/partially reliable]

Chief Complaints

Mrs. Bhuriya, a 70-year-old female, presented with:

Pain in the left eye for [duration].
Progressive diminution of vision in the left eye for [duration].
Redness and watering of the left eye for [duration].
History of thinning/ulceration of the cornea in the left eye.
History suggestive of recurrent herpetic eye disease in the same eye.

History of Present Illness

The patient was apparently well until [duration] ago, when she developed redness, watering, foreign-body sensation, photophobia, and pain in the left eye. The symptoms were followed by progressive diminution of vision. The pain was initially [mild/moderate/severe] and later became [progressive/intermittent/continuous].

She gives a history of prior episodes of redness, pain, watering, photophobia, or diminished vision in the same eye, suggestive of recurrent herpetic keratitis. Ask specifically about prior cold sores, fever blisters, facial vesicles, periocular rash, shingles, or previous diagnosis of herpes simplex virus infection.

Over the current episode, the patient noticed worsening vision with increasing corneal haze/whitening and was told that there was “corneal thinning.” There may be associated discharge, eyelid swelling, or foreign-body sensation. The history should clarify whether there was any trauma, contact-lens use, use of topical steroids, or use of traditional/herbal eye medications.

In herpetic keratitis, recurrent disease may involve the corneal epithelium, stroma, endothelium, or corneal nerves. A chronic non-healing epithelial defect with stromal melt can develop because prior herpetic disease reduces corneal sensation and causes neurotrophic keratopathy. The Wills Eye Manual, p. 223

Relevant Positive History

Recurrent unilateral left-eye disease: [Yes/No]
Previous diagnosis of herpetic keratitis: [Yes/No]
Previous episodes of vesicular lesions over eyelids/face/lips: [Yes/No]
Prior treatment with oral/topical antiviral therapy: [Specify]
Prior treatment with topical corticosteroid eye drops: [Specify duration and response]
Previous corneal ulcer/scar in the left eye: [Yes/No]
History of reduced corneal sensation or non-healing epithelial defect: [Yes/No]
History of diabetes mellitus, immunosuppression, malnutrition, chronic steroid use, or malignancy: [Specify]

Relevant Negative History

No history of recent ocular trauma: [Confirm]
No history of contact lens wear: [Confirm]
No history of chemical injury: [Confirm]
No history of recent intraocular surgery: [Confirm]
No similar complaint in the right eye: [Confirm]
No symptoms suggestive of retinal involvement, such as flashes, floaters, or a visual-field defect: [Confirm]

Past Ocular History

Previous episodes of left-eye redness, pain, or defective vision: [Specify number and timing]
Previous corneal ulcer or corneal scarring: [Yes/No]
Previous cataract surgery: [Yes/No, eye and date]
History of glaucoma or raised intraocular pressure: [Yes/No]
Previous use of topical steroids: [Yes/No]
Previous corneal procedures, amniotic membrane graft, tarsorrhaphy, or keratoplasty: [Yes/No]

Past Medical History

Document the following:

Diabetes mellitus
Hypertension
Tuberculosis
Autoimmune disease, especially rheumatoid arthritis or vasculitis
Chronic kidney disease
Immunocompromised state
HIV infection, malignancy, chemotherapy, or systemic corticosteroid use
Recurrent herpes labialis or herpes zoster

Drug History

Topical antiviral: [Ganciclovir/acyclovir/trifluridine, if used]
Oral antiviral: [Acyclovir/valacyclovir/famciclovir, if used]
Topical corticosteroid: [Drug, frequency, duration]
Topical antibiotics/lubricants: [Specify]
Any traditional medication or over-the-counter eye drops: [Specify]

Personal and Family History

Appetite, sleep, bowel and bladder habits: [Normal/abnormal]
No relevant family history of similar ocular disease: [If applicable]
No known drug allergy: [If applicable]

Examination

General Physical Examination

The patient was conscious, cooperative, and oriented to time, place, and person.

Pulse: [ ]/min
Blood pressure: [ ] mmHg
Temperature: [ ]
Random blood sugar: [ ] mg/dL
Evidence of immunosuppression/systemic illness: [Absent/present]

Ocular Examination

Visual Acuity

Eye	Unaided Visual Acuity	With Pinhole	Best-Corrected Visual Acuity
Right eye	[ ]	[ ]	[ ]
Left eye	[ ]	[ ]	[ ]

The left eye has marked diminution of vision. Exact acuity must be entered from the clinical record.

External Examination

Right Eye

Lids and adnexa: [Normal]
Conjunctiva: [Normal]
Cornea: [Clear/other]
Pupil: [Normal]
Lens: [Age-related cataract/pseudophakia/other]

Left Eye

Lids/adnexa: Look for periocular vesicles, lid edema, crusting, lagophthalmos, or reduced blink.
Conjunctiva: Circumcorneal congestion/ciliary injection may be present.
Cornea: The clinical photographs appear to show a markedly abnormal cornea with central/paracentral opacity and an area concerning for ulceration with thinning. The exact dimensions, depth, staining pattern, infiltrate, and Seidel-test result must be documented at the slit lamp.
Anterior chamber: Assess depth, cells/flare, hypopyon, fibrin, and signs of perforation.
Iris and pupil: Assess pupillary reaction, iris atrophy, synechiae, and transillumination defects.
Lens: Assess for cataract or pseudophakia.
Intraocular pressure: Measure only when it is clinically safe. Avoid applanation if perfor1. Case identification and presenting complaints
70-year-old female, Mrs Bhuriya, with left-eye pain, progressive diminution of vision, redness/watering, and reported corneal thinning in the setting of herpetic eye disease.

History of present illness
Timeline of symptoms, prior similar unilateral episodes, history of cold sores/skin vesicles, previous antiviral or steroid use, and possible triggers such as fever, sunlight, immunosuppression, trauma, or diabetes.
Ocular examination and photo documentation
Visual acuity, conjunctival congestion, corneal epithelial defect/ulcer, stromal infiltrate or opacity, degree and location of thinning, corneal sensation, anterior-chamber reaction, intraocular pressure, and Seidel test.
Provisional diagnosis and differential diagnosis
Likely possibilities include herpetic stromal keratitis with ulceration, neurotrophic keratopathy with corneal melt, or secondary microbial keratitis. Bacterial, fungal, and acanthamoeba keratitis must be excluded when there is an infiltrate and thinning.
Investigations
Slit-lamp examination with fluorescein staining, corneal-sensation testing, corneal scraping for microscopy/culture where infection is suspected, viral PCR in uncertain cases, intraocular pressure, dilated fundus examination, and systemic assessment including diabetes/immunosuppression.
Management and follow-up
Urgent cornea-specialist management, antiviral therapy, protective lubricants, treatment of any superadded infection, monitoring of thinning/perforation risk, and carefully supervised use of steroid only when appropriate with antiviral cover.

High-level overview

This is a high-risk unilateral corneal case in an elderly woman. The clinical history of herpetic eye disease plus pain, visual loss, and corneal thinning raises concern for severe herpetic keratitis, potentially with stromal involvement or a neurotrophic corneal ulcer. Recurrent herpes-related inflammation can reduce corneal sensation, cause a persistent epithelial defect, and progress to stromal melting, scarring, or perforation.

The photographs appear consistent with a severely diseased cornea with marked haze/opacity and a possible central or paracentral ulcerative-thinning process. However, the image alone cannot establish the exact type of keratitis or rule out secondary bacterial or fungal infection. This distinction is clinically important because treatment differs, particularly regarding topical corticosteroids.

Which topic would you like me to write in detail next: 1) full formal case presentation, 2) examination findings, 3) differential diagnosis, or 4) management plan?

Write the full formal ophthalmology case presentation

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Formal Ophthalmology Case Presentation

Patient Particulars

Name: Mrs. Bhuriya
Age/Sex: 70-year-old female
Eye involved: Left eye
Date of presentation: [Insert date]
Informant: Patient and/or attendant
Reliability of history: [Reliable/partially reliable]

Chief Complaints

Mrs. Bhuriya, a 70-year-old female, presented with:

Pain in the left eye for [duration].
Progressive diminution of vision in the left eye for [duration].
Redness, watering, and photophobia in the left eye for [duration].
History of recurrent herpetic eye disease involving the left eye.
History of corneal ulceration/thinning in the left eye.

History of Present Illness

The patient was apparently well until [duration] before presentation, when she developed redness, watering, foreign-body sensation, and pain in her left eye. The pain was associated with photophobia and progressive diminution of vision.

She has a history of recurrent episodes of similar unilateral left-eye complaints, suggestive of recurrent herpetic eye disease. Previous episodes may have been associated with corneal ulceration, corneal opacity, and reduction of vision. Details regarding the number of recurrences, duration of each episode, treatment taken, and response to treatment should be elicited.

In the present episode, the patient noticed worsening pain and reduced vision, followed by increasing corneal haze/whitening. She was subsequently noted to have corneal thinning. There is no definite history available of ocular trauma, contact-lens wear, chemical injury, or recent surgery in the affected eye.

The patient should be specifically asked about:

Previous cold sores, lip vesicles, facial vesicles, or periocular blisters.
Previous herpes zoster involving the forehead or tip of the nose.
Prior use of topical antiviral drops or oral antiviral drugs.
Previous or current unsupervised use of topical corticosteroid drops.
Previous corneal scraping, corneal ulcer, amniotic membrane grafting, tarsorrhaphy, or corneal transplantation.
Fever, ultraviolet-light exposure, emotional stress, or systemic illness preceding recurrence.
Diabetes mellitus, immunosuppression, chronic systemic steroid use, or malnutrition.

Herpetic keratitis may recur and involve the epithelium, stroma, endothelium, or corneal nerves. Repeated inflammation may result in corneal scarring, vascularization, thinning, and in severe cases perforation. Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed., p. 235.

Past Ocular History

History of recurrent left-eye herpetic keratitis: Present.
Previous episodes of redness, pain, photophobia, watering, and defective vision in the left eye: Present.
History of prior corneal ulcer or corneal scar: Likely present, to be confirmed.
History of topical steroid use: [Present/Absent/Unknown].
History of topical or oral antiviral therapy: [Present/Absent/Unknown].
History of glaucoma or raised intraocular pressure: [Present/Absent/Unknown].
History of cataract surgery or any other ocular surgery: [Present/Absent/Unknown].
No significant ocular complaints in the right eye: [Confirm].

Past Medical History

Relevant history should include:

Diabetes mellitus: [Present/Absent].
Hypertension: [Present/Absent].
Autoimmune disease, especially rheumatoid arthritis or vasculitis: [Present/Absent].
Immunosuppressive treatment, malignancy, HIV infection, or chronic systemic illness: [Present/Absent].
Chronic kidney disease: [Present/Absent].
Previous herpes labialis or herpes zoster infection: [Present/Absent].

This is important because diabetes, immunosuppression, and use of corticosteroids can contribute to a non-healing corneal epithelial defect, superadded infection, and corneal melt.

Drug and Allergy History

Current topical eye medications: [Specify name, dose, frequency, and duration].
Prior topical steroid use: [Specify].
Prior antiviral therapy: [Specify].
Systemic medications: [Specify].
History of traditional/herbal eye drop use: [Ask specifically].
Drug allergy: [Present/Absent].

Personal and Family History

Appetite: [Normal/Reduced]
Sleep: [Normal/Disturbed due to pain]
Bowel and bladder habits: [Normal]
Family history of similar ocular disease: [Absent]
No significant addiction history: [If applicable]

Examination

General Physical Examination

The patient is conscious, cooperative, and oriented to time, place, and person.

Pulse rate: [ ]/minute
Blood pressure: [ ] mmHg
Temperature: [ ]
Random blood sugar: [ ] mg/dL
General nutritional status: [Adequate/Poor]
Evidence of systemic immunosuppression or connective-tissue disease: [Absent/Present]

Ocular Examination

Visual Acuity

Eye	Unaided vision	Pinhole vision	Best corrected vision
Right eye	[ ]	[ ]	[ ]
Left eye	[ ]	[ ]	[ ]

The left eye has significant diminution of vision. Record vision precisely as counting fingers, hand movements, perception of light, or Snellen visual acuity as applicable.

External Examination

Right Eye

Lids and adnexa: Normal.
Conjunctiva: Normal.
Cornea: Clear.
Anterior chamber: Normal depth and quiet.
Pupil: Round, regular, and reacting to light.
Lens: [Clear/cataractous/pseudophakic].
Fundus: [Normal/describe].

Left Eye

Lids and adnexa: Examine for edema, crusting, vesicles, cicatricial change, lagophthalmos, and reduced blink.
Conjunctiva: Diffuse conjunctival and circumcorneal congestion may be present.
Cornea: Marked corneal opacity/haze with an ulcerative or thinned area is seen clinically. The available anterior-segment photographs show severe corneal disease with central to paracentral opacity and a suspicious area of stromal thinning.
Epithelial defect: Document exact size in millimeters after fluorescein staining.
Stromal infiltrate: Record its size, depth, margins, density, and whether there is surrounding edema.
Corneal thinning: Document the location and estimated percentage of residual stromal thickness.
Descemetocele/perforation: Rule out clinically with a Seidel test.
Corneal sensation: Must be assessed before instillation of topical anesthetic. Reduced corneal sensation supports herpetic neurotrophic keratopathy.
Corneal vascularization/scarring: Record if present, as it indicates chronic or recurrent corneal disease.
Anterior chamber: Assess depth, cells, flare, hypopyon, fibrin, and synechiae.
Iris: Look for iris atrophy, transillumination defects, and posterior synechiae.
Pupil: Note shape, size, and reaction.
Intraocular pressure: Measure only if there is no suspected perforation or marked corneal instability.
Lens and fundus: Examine as feasible after stabilization of the cornea.

In a herpetic neurotrophic ulcer, the cornea may have reduced sensation and a persistent epithelial defect with smooth margins, which can progress to stromal melting and perforation. The Wills Eye Manual, p. 223.

Clinical Interpretation of the Photographs

The photographs are consistent with a severely diseased left cornea showing:

Diffuse corneal haze/opacity.
Central or paracentral stromal involvement.
A possible ulcerative epithelial defect.
A suspicious area of marked corneal thinning.
Associated conjunctival congestion.

However, the photographs alone cannot reliably determine:

The exact depth or percentage of thinning.
Whether a descemetocele or microperforation is present.
Presence of an active dendritic/geographic epithelial lesion.
Whether there is a superadded bacterial or fungal infection.
The degree of anterior-chamber inflammation or intraocular pressure elevation.

Problem Representation

A 70-year-old woman with recurrent unilateral left-eye herpetic disease presents with pain, progressive visual loss, severe corneal opacity, and corneal thinning, raising concern for severe herpetic stromal keratitis with ulceration, neurotrophic keratopathy with corneal melt, or secondary microbial keratitis.

Provisional Diagnosis

Left eye recurrent herpetic keratitis with corneal ulceration and stromal thinning, likely herpetic stromal keratitis with associated neurotrophic keratopathy.

Rule out:

Secondary bacterial keratitis.
Secondary fungal keratitis.
Impending corneal perforation or descemetocele.
Herpetic keratouveitis with raised intraocular pressure.

Herpetic stromal keratitis with ulceration may cause suppurative stromal inflammation, epithelial defect, and corneal thinning. It can resemble bacterial, fungal, or parasitic keratitis; concurrent microbial infection must therefore be excluded. The Wills Eye Manual, p. 223.

Differential Diagnosis

Differential diagnosis	Supporting/against features
Herpetic stromal keratitis with ulceration	Recurrent unilateral disease, prior herpetic history, corneal opacity, stromal inflammation, ulceration, and thinning support this diagnosis.
Neurotrophic keratopathy following herpetic disease	Chronic non-healing epithelial defect, reduced corneal sensation, smooth-edged ulcer, and stromal melt favor this possibility.
Secondary bacterial keratitis	Must be excluded if there is dense infiltrate, mucopurulent discharge, rapidly increasing pain, hypopyon, or progressive thinning.
Fungal keratitis	Consider if there is trauma with vegetative matter, feathery-edged infiltrate, satellite lesions, or poor response to standard therapy.
Peripheral ulcerative keratitis	Consider if the thinning is peripheral with associated autoimmune disease, especially rheumatoid arthritis or vasculitis.
Exposure keratopathy	Consider if lagophthalmos, facial palsy, poor blink, or inferior exposure defect is present.

Investigations

Ocular Investigations

Visual acuity in both eyes.
Slit-lamp biomicroscopy with detailed ulcer charting.
Fluorescein staining to identify epithelial defect, dendritic/geographic ulcer, and to perform Seidel test.
Corneal sensation testing, before topical anesthesia.
Intraocular pressure measurement, when safe.
Corneal scraping from ulcer edge and base for:
- Gram stain
- KOH wet mount
- Giemsa stain
- Bacterial and fungal culture/sensitivity
HSV PCR/culture, if diagnosis is uncertain or disease is atypical.
Anterior-segment optical coherence tomography, if available, to assess depth of thinning.
B-scan ultrasonography, if the posterior segment is not visible.
Dilated fundus examination, once feasible, to rule out posterior herpetic involvement.

HSV keratitis is often a clinical diagnosis; PCR or culture may be useful when the diagnosis is uncertain. The Wills Eye Manual, p. 225.

Systemic Investigations

Complete blood count.
Random blood sugar, fasting blood sugar, and HbA1c.
Renal function tests before systemic antiviral therapy, particularly in an elderly patient.
Liver function tests if clinically indicated.
HIV testing if risk factors or recurrent severe disease are present, with informed consent.
Autoimmune work-up if peripheral ulceration or systemic connective-tissue disease is suspected.

Management Plan

Immediate Management

This patient requires urgent cornea-specialist assessment, preferably on the same day, because corneal thinning can progress to perforation and permanent visual loss.

Protect the cornea
- Avoid eye rubbing and pressure on the globe.
- Use a rigid eye shield if there is severe thinning or risk of perforation.
- Avoid patching an infected corneal ulcer.
- Avoid tonometry if frank perforation is suspected.
Document ulcer and thinning
- Record exact size, site, depth, infiltrate, epithelial defect, hypopyon, and Seidel result.
- Take serial photographs for comparison.
Corneal scraping
- Obtain corneal scraping for microbiology before starting or altering antimicrobial therapy, if an infiltrate or active ulcer is present.
Antiviral therapy
- Systemic antiviral therapy is generally preferred in significant herpetic keratitis because of ease of use and reduced topical corneal toxicity.
- In an elderly patient, renal function must be reviewed and the antiviral dose adjusted when needed.
Treat possible superadded infection
- If ulcerative stromal disease, infiltrate, discharge, or rapid progression is present, institute intensive topical antimicrobial therapy as guided by the treating ophthalmologist and microbiology results.
Lubrication and epithelial support
- Preservative-free lubricants frequently.
- Lubricating ointment, especially at night.
- Consider protective measures such as bandage contact lens, amniotic membrane transplantation, or temporary tarsorrhaphy only under corneal-specialist supervision.
Avoid unsupervised topical corticosteroid therapy
- Topical steroids can worsen active epithelial herpetic disease and may contribute to enlargement of ulceration and perforation.
- Steroids may have a role in immune stromal disease, but only after appropriate evaluation, with adequate antiviral cover, and close monitoring. Kanski's Clinical Ophthalmology: A Systematic Approach, 10th ed., p. 235.
Cycloplegia
- A cycloplegic may be required if there is pain due to ciliary spasm or associated anterior uveitis.
Manage raised intraocular pressure
- Check for herpetic trabeculitis or steroid-induced pressure elevation and treat under ophthalmic supervision.

Management if There Is Impending or Actual Perforation

If a descemetocele, positive Seidel test, or perforation is present:

Urgent corneal intervention is indicated.
Options depend on defect size and location and include tissue adhesive with bandage contact lens, amniotic membrane transplantation, conjunctival flap in selected eyes, or therapeutic keratoplasty.
The goal is to preserve globe integrity first, followed by infection control and visual rehabilitation.

Follow-up Plan

The patient should be reviewed very frequently, often daily initially, to monitor:

Visual acuity.
Pain and photophobia.
Ulcer dimensions and epithelial healing.
Corneal infiltrate and stromal thinning.
Seidel test.
Anterior-chamber reaction.
Intraocular pressure.
Culture results and treatment response.
Drug-related epithelial toxicity.

After acute healing, she requires long-term surveillance for recurrence, corneal scarring, vascularization, astigmatism, neurotrophic epithelial defects, cataract, and secondary glaucoma.

Final Case Summary

Mrs. Bhuriya is a 70-year-old female with recurrent left-eye herpetic disease who presented with pain, redness, watering, progressive diminution of vision, corneal opacity, and clinically suspected corneal ulceration with thinning. The most likely diagnosis is recurrent herpetic stromal keratitis with ulceration and corneal thinning, with possible associated neurotrophic keratopathy. Secondary bacterial or fungal infection and impending corneal perforation must be urgently excluded.

This is a vision-threatening condition requiring prompt slit-lamp assessment, corneal scraping where indicated, antiviral therapy, corneal-protective treatment, and close monitoring by a cornea specialist.

provisional diagnosis PUK or moorens

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Mooren ulcer peripheral ulcerative keratitis

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Mooren ulcer peripheral ulcerative keratitis diagnosis associated systemic disease

Revised Provisional Diagnosis

Left eye peripheral ulcerative keratitis (PUK) with severe peripheral corneal thinning/melt, likely Mooren ulcer, with impending corneal perforation.

More precise wording for the case sheet

Provisional diagnosis: Left-eye severe progressive peripheral ulcerative keratitis with crescentic peripheral corneal ulceration and stromal thinning, clinically suggestive of Mooren ulcer.

To rule out: PUK secondary to an underlying systemic autoimmune/vasculitic disorder and infectious keratitis, including recurrent herpetic keratitis with secondary corneal melt.

Why this wording is preferable

Mooren ulcer is a diagnosis of exclusion. It is an idiopathic, painful, progressive peripheral corneal ulceration with stromal thinning that begins at the limbus and may extend circumferentially and then centrally. In older patients, it is often unilateral. It should only be diagnosed after excluding ocular infection and systemic diseases known to cause PUK, as summarized in EyeWiki's diagnostic criteria.

PUK is the broader clinical diagnosis. It can be associated with rheumatoid arthritis, granulomatosis with polyangiitis, systemic lupus erythematosus, relapsing polychondritis, inflammatory bowel disease, and other vasculitic/collagen-vascular diseases. A patient with apparently isolated PUK requires systemic evaluation. Kanski's Clinical Ophthalmology, p. 241

Important point regarding herpetic eye disease

A prior history of herpetic eye disease is relevant but does not by itself confirm that the current thinning is herpetic. HSV stromal keratitis can mimic peripheral inflammatory ulceration and must be excluded, particularly if there is active epithelial disease, decreased corneal sensation, dendritic/geographic ulceration, or a history of recurrence. It may also coexist with or trigger peripheral ulcerative disease.

Investigations needed before labeling it Mooren ulcer

Corneal scraping for Gram stain, KOH mount, and bacterial/fungal culture.
HSV PCR or viral testing if active herpetic keratitis is suspected.
Complete blood count, ESR, CRP.
Rheumatoid factor and anti-CCP antibodies.
ANA and ANCA profile.
Urine routine examination and renal-function tests, especially to screen for systemic vasculitis.
Hepatitis B and C screening.
Rheumatology consultation where indicated.

If these investigations show no infection and no associated autoimmune/vasculitic disorder, the diagnosis can be stated as:

Left-eye Mooren ulcer, unilateral type, with progressive peripheral corneal melt/thinning and risk of perforation.

Rewrite the full case with PUK ulcer as the diagnosis

Formal Ophthalmology Case Presentation

Identification Data

Name: Mrs. Bhuriya
Age/Sex: 70-year-old female
Eye involved: Left eye
Date of presentation: [Insert date]
Informant: Patient and attendant
Reliability of history: Partially reliable

Chief Complaints

Mrs. Bhuriya, a 70-year-old female, presented with:

Pain in the left eye for [duration].
Progressive diminution of vision in the left eye for [duration].
Redness, watering, and photophobia in the left eye for [duration].
Progressive corneal ulceration and thinning in the left eye for [duration].

History of Present Illness

The patient was apparently well until [duration] before presentation, when she developed redness, watering, foreign-body sensation, and pain in the left eye. The symptoms were associated with photophobia and gradual diminution of vision.

The pain was [mild/moderate/severe], progressive in nature, and associated with worsening redness and blurred vision. Subsequently, she noticed increasing opacity of the cornea, with a non-healing ulcerative lesion and progressive thinning of the cornea in the left eye.

There is a history of previous episodes of left-eye redness, pain, watering, and defective vision, with a past history suggestive of herpetic eye disease. Details of previous treatment with topical antiviral drugs, oral antiviral drugs, topical corticosteroids, and antibiotics should be documented.

There is no definite history of:

Ocular trauma
Contact-lens wear
Chemical injury
Recent ocular surgery
Use of traditional or herbal eye medications

A history of systemic symptoms should be elicited carefully, including joint pain or swelling, prolonged morning stiffness, recurrent oral or genital ulcers, skin rash, nasal crusting or epistaxis, cough, hematuria, weight loss, fever, inflammatory bowel disease, or ear/nose cartilage inflammation. These symptoms may suggest an underlying systemic autoimmune or vasculitic illness associated with peripheral ulcerative keratitis.

Past Ocular History

History of recurrent unilateral inflammation in the left eye: Present.
History suggestive of previous herpetic eye disease: Present.
History of previous corneal ulcer/scarring: Likely present.
History of topical corticosteroid use: [Present/Absent/Unknown].
History of topical or oral antiviral treatment: [Present/Absent/Unknown].
Previous ocular surgery: [Absent/Specify].
History of glaucoma or raised intraocular pressure: [Absent/Specify].
Similar complaints in the right eye: [Absent/Present].

Past Medical History

The patient should be assessed for:

Diabetes mellitus
Hypertension
Rheumatoid arthritis
Systemic lupus erythematosus
Granulomatosis with polyangiitis
Relapsing polychondritis
Inflammatory bowel disease
Tuberculosis
Chronic kidney disease
Hepatitis B or hepatitis C
Immunosuppression, malignancy, or long-term systemic steroid use

At present, the history of systemic autoimmune disease is [not elicited/not known/absent], and a systemic work-up is required.

Drug History

Current topical medications: [Specify drug, frequency, and duration].
Previous topical corticosteroid use: [Specify].
Previous antiviral treatment: [Specify].
Previous topical antibiotic use: [Specify].
Systemic medication: [Specify].
Drug allergy: [Present/Absent].

Personal and Family History

Appetite: [Normal/Reduced]
Sleep: [Disturbed due to pain/Normal]
Bowel and bladder habits: [Normal/Abnormal]
Family history of autoimmune or rheumatological disease: [Absent/Present]
Addiction history: [Nil/Specify]

Examination

General Physical Examination

The patient is conscious, cooperative, and oriented to time, place, and person.

Pulse: [ ]/minute
Blood pressure: [ ] mmHg
Temperature: [ ]
Random blood sugar: [ ] mg/dL
General nutritional status: [Adequate/Poor]
Pallor/Icterus/Cyanosis/Clubbing/Lymphadenopathy/Edema: [Absent/Present]

Look specifically for evidence of systemic autoimmune disease, including joint deformity, skin rash, vasculitic lesions, auricular or nasal cartilage inflammation, oral ulcers, and signs of renal or respiratory involvement.

Ocular Examination

Visual Acuity

Eye	Unaided visual acuity	Pinhole	Best-corrected visual acuity
Right eye	[ ]	[ ]	[ ]
Left eye	[ ]	[ ]	[ ]

Vision in the left eye is significantly reduced. Exact vision should be recorded as Snellen acuity, counting fingers, hand movements, or perception of light as applicable.

External Examination

Right Eye

Lids and adnexa: Normal.
Conjunctiva: Normal.
Cornea: Clear.
Anterior chamber: Normal depth and quiet.
Pupil: Round, regular, and reacting to light.
Lens: [Clear/cataractous/pseudophakic].
Fundus: [Normal/describe findings].

Left Eye

Lids and Adnexa

Examine for lid edema, blepharitis, lagophthalmos, trichiasis, periocular vesicles, facial rash, or reduced blink.
[Findings to be documented.]

Conjunctiva

Diffuse conjunctival congestion with circumcorneal congestion is present.
Assess for adjacent conjunctival inflammation, episcleritis, or scleritis.

Cornea

The left cornea shows a peripheral crescentic ulcerative lesion with stromal thinning, consistent with peripheral ulcerative keratitis.

Document the following precisely on slit-lamp examination:

Site: [Nasal/temporal/superior/inferior peripheral cornea].
Extent: [Clock hours involved].
Ulcer: Peripheral, crescentic ulceration close to the limbus.
Epithelial defect: [Present/Absent], size [ ] mm × [ ] mm.
Stromal infiltrate: [Present/Absent], size and depth [ ].
Thinning: [Percentage of stromal thinning, if assessable].
Edge of ulcer: [Undermined/overhanging/active].
Corneal vascularization: [Present/Absent].
Adjacent scleral involvement: [Present/Absent].
Corneal sensation: [Reduced/normal], to be tested before topical anesthesia.
Descemetocele: [Present/Absent].
Seidel test: [Positive/Negative].

The provided photographs show a markedly diseased left cornea with diffuse opacity and severe ulcerative thinning. However, the exact clock-hour involvement, depth of melt, and integrity of the globe must be determined by slit-lamp biomicroscopy.

Anterior Chamber

Depth: [Normal/Shallow]
Cells and flare: [Present/Absent]
Hypopyon: [Present/Absent]
Fibrin: [Present/Absent]
Posterior synechiae: [Present/Absent]

Iris and Pupil

Iris pattern: [Normal/Atrophy/Transillumination defects]
Pupil size and reaction: [ ]
Shape: [Round/Irregular/Peaked]

A peaked pupil or shallow anterior chamber may indicate an occult corneal perforation.

Intraocular Pressure

Right eye: [ ] mmHg
Left eye: [ ] mmHg, only if it is safe to measure and there is no suspected perforation.

Lens and Posterior Segment

Lens: [Clear/Cataractous/Pseudophakic].
Fundus examination: [Normal/Not visible due to corneal opacity].
If fundus is not visible, perform B-scan ultrasonography to assess posterior-segment status.

Problem Representation

A 70-year-old woman with recurrent unilateral left-eye inflammation and a history suggestive of herpetic eye disease presents with pain, redness, photophobia, diminished vision, peripheral corneal ulceration, and progressive stromal thinning.

Provisional Diagnosis

Left-eye peripheral ulcerative keratitis with progressive peripheral corneal ulceration and stromal thinning, with impending corneal perforation.

Because she has a previous history suggestive of herpetic eye disease, herpes simplex keratitis and secondary infective keratitis must be excluded before beginning systemic immunosuppression.

Differential Diagnosis

Mooren ulcer
- A painful, progressive, peripheral ulcerative keratitis that begins near the limbus and may extend circumferentially or centrally.
- It is diagnosed only after infection and systemic autoimmune/vasculitic causes have been excluded.
PUK secondary to systemic autoimmune or vasculitic disease
- Rheumatoid arthritis
- Granulomatosis with polyangiitis
- Systemic lupus erythematosus
- Relapsing polychondritis
- Polyarteritis nodosa
- Inflammatory bowel disease
Herpetic stromal keratitis with corneal melt
- Important because of prior herpetic eye disease and recurrent unilateral involvement.
Secondary bacterial or fungal keratitis
- Must be excluded in the presence of an epithelial defect, infiltrate, discharge, hypopyon, or rapid corneal melting.
Terrien marginal degeneration
- Less likely if there is significant pain, active ulceration, epithelial defect, and inflammation.
Marginal keratitis or peripheral infective keratitis
- Consider based on lid disease, infiltrate, and microbiological findings.

PUK is a clinical syndrome characterized by peripheral corneal ulceration and stromal melt. It can be associated with severe systemic vasculitis and may progress to descemetocele or perforation. Kanski's Clinical Ophthalmology, 10th ed., p. 241.

Investigations

Ocular Investigations

Detailed slit-lamp biomicroscopy and serial corneal ulcer charting.
Fluorescein staining to document epithelial defect and perform Seidel test.
Corneal sensation testing before instillation of topical anesthetic.
Corneal scraping from the ulcer edge and base for:
- Gram stain
- KOH wet mount
- Giemsa stain
- Bacterial culture and sensitivity
- Fungal culture
HSV PCR/corneal viral testing if active herpetic keratitis is suspected.
Intraocular pressure measurement when safe.
Anterior-segment OCT to assess residual stromal thickness, if available.
Slit-lamp photography for serial documentation.
B-scan ultrasonography if fundus is not visualized.

Systemic Investigations

Complete blood count with differential count.
ESR and C-reactive protein.
Random blood sugar, fasting blood sugar, and HbA1c.
Renal-function tests and liver-function tests.
Urine routine examination and urine microscopy for hematuria/proteinuria.
Rheumatoid factor and anti-CCP antibody.
ANA profile.
ANCA profile, especially c-ANCA/PR3-ANCA, where granulomatosis with polyangiitis is suspected.
Hepatitis B and C serology.
HIV testing when indicated, with informed consent.
Chest radiograph and rheumatology/physician evaluation if systemic features are present.

Management Plan

Immediate Measures

Urgent cornea-specialist review
Progressive PUK with thinning is a corneal emergency because it can rapidly result in perforation and irreversible visual loss.
Assess globe integrity
- Perform Seidel test.
- Avoid pressure on the globe.
- Avoid applanation tonometry if severe thinning or perforation is suspected.
- Use a rigid eye shield if there is risk of perforation.
Obtain corneal scrapings before altering antimicrobial treatment
This is essential to exclude bacterial, fungal, and herpetic infection.
Stop potentially harmful medication
- Stop unsupervised topical anesthetics.
- Stop inappropriate topical steroid use until infection has been assessed.
- Avoid topical nonsteroidal anti-inflammatory eye drops because they can worsen corneal melting.
Start topical antimicrobial cover if infection is possible
Choice and frequency should be guided by the corneal specialist, clinical appearance, and microbiology.
Frequent preservative-free lubricants
- Preservative-free tear substitutes frequently.
- Lubricating ointment at bedtime.
Cycloplegic agent
- If pain due to ciliary spasm or associated anterior uveitis is present.
Manage associated ocular surface disease
- Treat blepharitis, dry eye, lagophthalmos, trichiasis, or exposure if present.

Disease-Specific Management After Infection Is Excluded

If the diagnosis of immune-mediated PUK is confirmed:

Topical corticosteroids may be used cautiously under close corneal supervision.
Systemic corticosteroid therapy may be required for rapidly progressive ulceration.
Systemic immunosuppressive therapy may be required in severe, progressive, or autoimmune-associated PUK.
Rheumatology consultation is essential if systemic autoimmune disease is detected or strongly suspected.
In a suspected Mooren ulcer, immunomodulatory treatment and local surgical measures may be required after exclusion of infection and systemic disease.

In the setting of prior herpetic disease, any decision to use corticosteroid or systemic immunosuppression should be made by the treating ophthalmologist with appropriate antiviral consideration and close monitoring.

Management of Severe Thinning or Perforation

If there is a descemetocele, microperforation, positive Seidel test, or impending perforation:

Cyanoacrylate tissue adhesive with bandage contact lens may be considered for a small perforation.
Amniotic membrane transplantation may assist epithelial healing and surface reconstruction in selected cases.
Conjunctival resection or recession may be considered in refractory Mooren ulcer.
Lamellar or therapeutic penetrating keratoplasty may be needed for extreme thinning, large perforation, or uncontrolled disease.
The primary aim is preservation of globe integrity, followed by control of inflammation/infection and later visual rehabilitation.

Follow-up Plan

Initially, the patient requires close follow-up, often daily, to assess:

Visual acuity
Pain and photophobia
Size and depth of the peripheral ulcer
Degree of stromal thinning
Epithelial healing
Seidel test
Anterior-chamber reaction
Intraocular pressure
Culture results
Development of descemetocele or perforation
Response to topical and systemic therapy

Final Case Summary

Mrs. Bhuriya is a 70-year-old female with left-eye pain, redness, watering, photophobia, progressive diminution of vision, and peripheral corneal ulceration with thinning. The clinical diagnosis is:

Left-eye peripheral ulcerative keratitis with progressive peripheral corneal melt/thinning and risk of impending perforation.

Mooren ulcer is an important diagnostic possibility, but it should be confirmed only after excluding corneal infection and systemic autoimmune or vasculitic disease. Her prior history suggestive of herpetic eye disease is clinically important and warrants careful exclusion of active or recurrent herpetic keratitis before initiating immunosuppressive treatment.

how to approach a case of perforated corneal ulcer with iris incarceration with pseudocornea

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corneal perforation iris prolapse management

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corneal perforation iris prolapse management tissue adhesive therapeutic keratoplasty review

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corneal perforation iris prolapse pseudocornea clinical photograph

A perforated corneal ulcer with iris incarceration and pseudocornea is an ocular emergency. The immediate priorities are to preserve globe integrity, control infection or inflammation, and prevent endophthalmitis. A pseudocornea forms when prolapsed iris becomes covered by epithelium and fibrous tissue after a perforation, producing an opaque anterior corneal surface with an adherent iris plug.

1. Initial approach

A. Do not manipulate the eye

Do not attempt to pull or push the incarcerated iris at the slit lamp.
Do not perform applanation tonometry.
Avoid pressure patching, eye rubbing, or any pressure over the globe.
Place a rigid protective eye shield.
Assess and document visual acuity, including perception of light and projection of rays, if vision is severely reduced.

B. Assess whether perforation is active or sealed

At slit lamp, document:

Site and size of the perforation
Central or peripheral location
Size of epithelial defect and infiltrate
Amount of stromal melt/thinning
Iris prolapse/incarceration
Anterior-chamber depth
Pupil shape, especially a peaked pupil toward the perforation
Hypopyon, fibrin, cataract, or lens involvement
Seidel test only if appropriate and safe

A negative Seidel test does not exclude an old or self-sealed perforation. Iris incarceration may plug the defect, and later epithelialization over the iris can create pseudocornea.

2. Establish the cause before definitive anti-inflammatory therapy

The case should be approached as:

Perforated corneal ulcer with iris incarceration and pseudocornea, secondary to [suspected infectious / herpetic / peripheral ulcerative keratitis / Mooren ulcer / neurotrophic keratopathy].

Important etiologies include:

Infectious keratitis
- Bacterial
- Fungal
- Herpetic
- Acanthamoeba, where relevant
Immune-mediated peripheral ulcerative keratitis
- Rheumatoid arthritis
- Granulomatosis with polyangiitis
- Other systemic vasculitis or collagen-vascular disorders
Mooren ulcer
- Consider only after excluding infection and systemic autoimmune disease.
Neurotrophic keratopathy
- Especially with prior herpetic disease, diabetes, exposure, or reduced corneal sensation.

Corneal scraping for microscopy and bacterial/fungal culture should be obtained from any active ulcer edge or infiltrate, where feasible, before changing antimicrobial therapy. If herpetic disease is possible, assess corneal sensation and consider HSV testing in atypical cases.

3. Decide whether the eye needs emergency surgical sealing

Small perforation, stable eye

For a small, focal perforation with limited tissue loss, a corneal surgeon may use:

Cyanoacrylate tissue adhesive
Bandage contact lens after adhesive application
Intensive medical treatment for the underlying cause

Tissue adhesive is typically used for small perforations, often up to about 2 to 3 mm, but suitability depends on site, tissue loss, infection, anterior-chamber stability, and surgeon assessment. The AAO review on tissue adhesives describes their role in acute small corneal perforations and severe corneal thinning.

Large perforation, significant tissue loss, uncontrolled melt, or flat/shallow anterior chamber

These require urgent operating-room management, such as:

Removal of nonviable prolapsed iris only if required
Gentle repositioning of viable iris when feasible
Restoration of the anterior chamber with viscoelastic or air
Therapeutic or tectonic keratoplasty
Lamellar patch graft or corneoscleral patch graft for peripheral defects
Amniotic membrane transplantation in selected surface defects
Conjunctival resection/recession in selected inflammatory ulcers, including refractory Mooren ulcer

Penetrating keratoplasty may be required to restore globe integrity in a large or non-sealable perforation. EyeWiki's perforation management summary notes the role of tissue adhesive for selected small defects and keratoplasty for larger or severe perforations.

4. Handling the iris incarceration and pseudocornea

If recent iris prolapse

Treat as an open globe/corneal perforation.
Urgent surgical exploration is usually required.
The surgeon assesses whether the iris is viable and whether it can be gently reposited.
Necrotic, contaminated, or nonviable iris tissue may need excision.
Reform the anterior chamber and seal the corneal defect.

If old, sealed perforation with pseudocornea

Do not try to separate the pseudocornea or iris adhesion at the slit lamp.
First determine whether there is active ulceration, melt, infection, leak, or intraocular inflammation.
If stable and epithelialized, the immediate aim is observation, ocular-surface optimization, treatment of the underlying disease, and planning later visual rehabilitation.
If central pseudocornea significantly blocks the visual axis, later optical rehabilitation may require staged corneal reconstruction or keratoplasty after the eye is quiet and the cause is controlled.

5. Medical treatment while arranging definitive care

Treatment is cause-specific and should be supervised by a cornea specialist:

Topical broad-spectrum antimicrobial therapy if infectious keratitis has not been excluded.
Systemic and/or topical antiviral therapy if herpetic keratitis is active or strongly suspected.
Cycloplegic for pain from ciliary spasm and associated anterior uveitis.
Preservative-free lubricants and surface protection.
Systemic analgesia and antiemetics, because vomiting or straining can worsen leakage.
Avoid topical anesthetic abuse.
Avoid topical steroid until active infection is adequately excluded or controlled.

For immune PUK or Mooren ulcer, systemic corticosteroids and immunosuppressive therapy may be needed, but only after microbiological evaluation and systemic work-up. In a patient with prior herpetic disease, immunosuppression requires careful antiviral cover and close monitoring.

6. Systemic work-up in PUK/Mooren-ulcer-type cases

Order or arrange:

CBC, ESR, CRP
Blood glucose and HbA1c
Renal and liver function tests
Urine routine and microscopy
Rheumatoid factor and anti-CCP
ANA profile
ANCA testing
Hepatitis B and C screening
Rheumatology review when systemic vasculitis is suspected

7. Key examination statement for a case presentation

Left eye: A [central/peripheral] corneal perforation with surrounding ulceration and stromal thinning is present. The iris is incarcerated in the perforation, producing a peaked pupil and an adherent iris plug. The area is covered by epithelium/fibrovascular tissue, forming pseudocornea. The anterior chamber is [formed/shallow/flat]. Seidel test is [positive/negative/not performed because of a fragile globe]. There is [presence/absence] of active infiltrate, hypopyon, and adjacent scleritis.

Practical bottom line

Protect the eye and avoid manipulation.
Confirm active versus sealed perforation.
Culture any active ulcer.
Control infection before immunosuppression.
Use glue only for selected small, stable defects.
Urgently perform tectonic surgery when there is a large defect, ongoing melt, iris prolapse, or unstable anterior chamber.
Treat the underlying cause to prevent recurrent melt and loss of the globe.

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