A 62-year-old man presented with a painless decrease in visual acuity (VA) in his left eye (LE) for two days.
He had come 2 months before for red eye, diagnosed with conjunctivitis, and treated with a fixed combination of dexamethasone and tobramycin.
Then VA was 1 and IOP 14mmHg in both eyes.
Personal history included diabetes mellitus, hypertension, obesity, hepatic steatosis, hyperthyroidism, ischemic heart disease and renal transplantation due to chronic renal failure secondary to chronic pyelonephritis.
The systemic medical treatment included prednisone 5mg/24h (Prednisone Alonga®, Sanofi Aventis), tacrolimus (Prograf®, MSD) and mycophenolate mofetil (Cellcept®).
The initial examination was VA of 1 in the right eye (OD) and 0.1 in the left eye, normal biomicroscopy in the right eye, in the left eye there was intense conjunctival injection and delustrated cornea without central redness with mild discoloration.
IOP was 18mmHg in RE and 46mmHg in LE.
The eye fundus was visualized with difficulty due to corneal edema, but the papilla and macula were normal, with applied retina without peripheral lesions.
In gonioscopy, the angle was open, without synechiae or neovessels.
During the exploration, the patient's drowsiness and some respiratory difficulty were observed.
He also had short stature, moderate obesity and short neck.
The initial diagnosis was ocular hypertension in OI, and treatment was established with fixed combination of 0.2% brimonidine and 0.5% thymolol maleate (Combigan®, Allergan).
She was referred to the glaucoma clinic and to the pulmonology department, who subsequently diagnosed severe apnea-hypopnea syndrome.
One week later, the VA was 0.1 and there was persistent conjunctival hyperemia, mild superficial corneal oedema, with IOP of 40mmHg.
Pachymetry was 512μm in RE and 574μm in LE (increment justified by corneal oedema).
A differential diagnosis was made between a carotid-aortic fistula and an orbital apex syndrome. A CT scan was requested.
Treatment was switched to brinzolamide (Azopt®, Alcon Cusi), tafluprost (Saflutan®, MSD) and diclofenac sodium (Diclofenacinioleporu®).
Two days later, IOP remained at 30 Aventis mmHg, so that acetazolamide (Edemox®, Chiesi-Spanish) and prednisone 60 mg (Prednisone Sanofi Alonga®) were administered.
1.
Hyperemia decreased progressively, and corticoids were reduced paulatinely, but IOP remained above 26mmHg.
CT ruled out any orbital and/or cranial disease.
At 5 weeks, a peripheral ulcer of unknown appearance appeared with positive staining for fluorescein and topical inraxvi borders. Corneal scraping was performed for culture and detection of C-reactive virus protein (K-reactive virus).
Microbiological analysis confirmed HVS positivity.
With this treatment, the corneal lesion healed leaving a small peripheral leukoma, IOP normalized and visual acuity reached 0.8.
