Reactivation of herpes simplex viral keratitis following the botulinum toxin injection

Abstract

We describe a case of 55-year-old male farmer presented with recurrent corneal abrasions with a spastic entropion in the left eye. Superior cornea showed typical nummular opacities suggestive resolved herpetic eye diseases. On further enquiry, he had similar episodes in the past. Contralateral eye was essentially normal. Following the botulinum toxin injection for the management of spastic entropion, subject developed reactivation of herpetic necrotizing stromal keratitis. Diagnostic corneal scrapings were negative for herpes simplex virus-1 antigen by immunofluorescence assay and for DNA by molecular techniques. The case was successfully managed with topical steroids and antiviral medications.

Figure 1

(a-d) The left eye corneal digital images of clinical course as observed in a chronological sequence. (a): At presentation, corneal epithelial abrasions were seen, where ever eyelashes brush against cornea due to lower lid spastic entropion (black curved arrow). Superiorly, tell-tale of herpetic stromal scarring noted (white arrow). (b) Typical fluorescein stained herpetic necrotizing stromal keratitis, which developed 1 week after periocular botulinum injection for a spastic entropion correction. (c) Resolving necrotizing stromal keratitis. (d) Recent slit lamp image taken 2 years after the initial botulinum injection showing extensive anterior stromal scarring due to recurrent episodes of stromal diseases (black arrow). Images a and b were captured through external digital camera and whereas c and d through slit lamp photography