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BMJ Case Rep. 2010; 2010: bcr11.2009.2497.
Published online May 19, 2010. doi:  10.1136/bcr.11.2009.2497
PMCID: PMC3047539
Unusual association of diseases/symptoms
A rare case of disciform keratitis in a silicone-filled eye presenting with ‘sticky oil’ on the endothelium.
Mae-Lynn Catherine Bastion and Aida Zairani Mohd Zahidin
Universiti Kebangsaan Malaysia, Ophthalmology, Hospital Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur, 56000, Malaysia
Correspondence to Mae-Lynn Catherine Bastion, maelynnb2003/at/yahoo.com
Abstract
An unusual case of disciform keratitis developing in a patient with silicone oil-filled eye following vitrectomies for posterior globe rupture.
Background
We present an unusual presentation of disciform keratitis in a silicone-filled eye whereby the endothelial inflammation caused oil globules to stick onto the endothelium only in the affected area of cornea.
A 66-year-old Chinese man with history of right posterior scleral perforation, phacodonesis and retinal detachment underwent two vitrectomies, lensectomy and silicone oil injection with post-operative unaided aphakic vision of 6/36. He presented 10 months later with a painful red right eye and decreased vision of 6/60. His intraocular pressure was 14 mmHg on guttae Timolol and guttae Brimonidine bd for angle recession glaucoma. There was paracentral corneal stromal oedema with endothelial pigment dusting and pigmented, emulsified, oil droplets on the corneal endothelium in the vicinity of the oedematous cornea only (figure 1). There was reduced corneal sensation and occasional anterior chamber cellular reaction. The patient could not give a history of herpetic eye disease. A diagnosis of disciform keratitis was made based on clinical appearance.
Figure 1
Figure 1
Slit lamp examination showing small oil globules in the vicinity of the oedematous cornea.
Investigations
Anterior chamber tap for PCR for herpetic genome was considered but the facility is not readily available at our institution. Furthermore, the patient was unable to bear the cost. However, it should be performed when available for definitive diagnosis.
Differential diagnosis
Corneal decompensation.
Treatment
The patient responded to a course of right topical aciclovir five times per day and guttae bethamethasone four times hourly with relief of symptoms. Aciclovir was continued for 3 months and steroid was slowly tapered.
Outcome and follow-up
There was complete resolution of the oedema by 2 months with a residual stromal opacity in the area. The emulsified oil droplets subsequently dispersed by 2 months. Ten months after this acute presentation, he underwent removal of silicone oil and his vision at final review was 6/36 with +10D lens. He is scheduled for secondary intraocular lens implantation at a later date. The cornea remains clear centrally.
Disciform keratitis is usually attributed to reactivation of herpes simplex virus in previously infected eyes with an autoimmune component; hence, the concurrent usage of topical steroids as stipulated in the Herpetic Eye Diseases Study.1 It has been reported as an uncommon occurrence in eyes after surgery such as Lasik.2 Herpetic stromal keratitis is a potentially blinding corneal disease.3 Disciform disease is primarily an inflammatory reaction within the endothelium with endothelitis and only secondary stromal oedema in the absence of stromal inflammation or neovascularisation.3 Hence, the presence of a sticky inflamed endothelium, which promotes the adhesion of emulsified oil. Emulsified silicone oil in the anterior chamber is a common finding in silicone-filled eyes.
To our best knowledge, this report is the first to document emulsified oil adherent to an area of disciform keratitis in a silicone oil-filled eye.
Learning points
  • Adherence of emulsified oil to a specific area of the endothelium is a useful marker of inflammation in the corneal segment.
  • Herpes simplex viral keratitis may occur in healthy individuals with previous exposure to the virus, particularly in eyes that have undergone previous intraocular surgery or insults such as repeat vitrectomies.
  • Disciform keratitis in silicone-filled eyes should be treated with conventional topical anti-virals and steroids to prevent further adhesion of the oil to the cornea, which may promote corneal decompensation.
Footnotes
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.
REFERENCES
1. Barron BA, Gee L, Hauck WW, et al. Herpetic Eye Disease Study. A controlled trial of oral acyclovir for herpes simplex stromal keratitis. Ophthalmology 1994; 101: 1871–82. [PubMed]
2. Levy J, Lapid-Gortzak R, Klemperer I, et al. Herpes simplex virus keratitis after laser in situ keratomileusis. J Refract Surg 2005; 21: 400–2. [PubMed]
3. Jared EK, Robert LH, Charukamnoetkanok Puwat. Management of herpes simplex virus stromal keratitis: an evidence-based review. Surv Ophthalmol 2009; 54: 226–3. [PubMed]
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