A 71-year-old woman with a history of type 2 diabetes mellitus was referred for a corneal ulceration of probable herpetic aetiology of the left eye of two months' evolution, accompanied by mild ocular pain. The patient reported having suffered ocular inflammation associated with frontal dermatitis, compatible with herpes zoster, two years earlier. At the first visit, she had a visual acuity of 0.4 in the right eye and a finger count at 1 metre in the left eye, a mild bilateral cataract, normal tonometry and fundus without significant alterations in both eyes. In the left eye, a superficial and central corneal ulceration was observed, with well-demarcated infiltrates at the edges, associated with an inflammatory reaction in the anterior chamber (cellular tyndall 2+).
Samples were taken for microbiological culture by corneal scraping, and oral itraconazole 200 mg/24h associated with topical treatment with amphotericin B 0.15%, cefazolin 50 mg/ml and tobramycin 15 mg/ml was prescribed, based on the main suspicion of fungal keratitis. The culture showed growth of Candida albicans, for which reason the same treatment was maintained. The keratitis rapidly worsened to corneal perforation within 6 days, preceded by a significant increase in pain, severe hyperemia, extension of the corneal epithelial defect, appearance of dense stromal infiltration (necrosis), hypopyon and ocular hypertension. An emergency amniotic membrane transplant (triple layer) was performed, preceded intraoperatively by a new corneal scraping for microbiological culture. The result of this culture (aerobic and anaerobic) was negative for bacteria.
Intravenous administration of voriconazole (200 mg/24 h) associated with oral aceclofenac, preservative-free artificial tears and topical brimonidine was started as medical treatment. After 10 days, intravenous voriconazole was replaced by oral voriconazole (200 mg/24 h) and continued for 6 weeks. The clinical picture responded favourably to treatment, with inflammatory signs progressively disappearing during the first 15 days. The patient presented only blurred vision at the beginning of the treatment and a slight increase of LDH in the blood, with no other side effects. Good integration of the amniotic membrane graft was observed, although a penetrating keratoplasty was subsequently required due to residual corneal scarring (adherent leukoma).