Herpetic uveitis or leaky lens?

A 22-year-old man had gradual, painless diminution of vision in the right eye for over two years. Corrected vision was hand movements. Following blunt trauma 10 years ago, he had mild blurring that remained stable. Recently, he was diagnosed elsewhere with herpes simplex virus (HSV) keratouveitis with secondary angle-closure glaucoma. He had no redness or pain. The right eye showed corneal edema, several non-granulomatous and granulomatous keratic precipitates, flare, and flocculent cataract [Figures 1 and 2]. Intraocular pressure (IOP) was 42 mmHg. There was no epithelial or stromal keratitis, iris atrophy, or transillumination defects.Figure 1: Multiple diffuse medium-sized keratic precipitates all over the corneal endotheliumFigure 2: A flocculent cataract with fluid content. The pink arrow points to a small area of anterior capsular fibrosis possibly due to breach from blunt trauma with defective healing, allowing fluid transport across itUltrasonography showed moderate vitreous echoes. A provisional diagnosis of phacogenic uveitis and glaucoma (due to possible late lens protein leak) was made with a differential diagnosis of atypical herpetic endotheliitis with uveitis. The left eye was normal. He underwent combined cataract surgery with trabeculectomy under steroid cover to address the cataract, secondary glaucoma, and inflammation. Polymerase chain reaction (PCR) of aqueous aspirate taken intraoperatively was negative for HSV. At six weeks, the right eye had quietened completely with corrected vision of 20/25;N6, a good filtering bleb, and controlled IOP of 10 mmHg [Figure 3].Figure 3: Shows a quiet eye six weeks after the triple procedureDiscussion Clinical findings supporting possible HSV endotheliitis with uveitis were diffuse keratic precipitates and increased IOP.[1] However, absence of inflammatory symptoms or recurrent episodes, unusual presentation of flocculent cataract, and PCR negativity were against this. Blunt trauma can either cause immediate rupture of the lens capsule and flocculent cataract or a late cataract, usually of rosette type without fluid imbibition.[2] The cataract in our case, though late-onset, was flocculent with fluid content. This signified possible slow movement of protein and fluid across the lens capsule, which aided the diagnosis. It is important to distinguish the above two conditions as the type and timing of treatment differ. In HSV keratouveitis, the eye should be quiescent before cataract surgery. While in phacogenic uveitis, the causative lens needs to be removed early and triple procedure under steroid cover is imperative to control glaucoma and uveitis.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.