case_images: PMC7767725_01
case_images: HSV stromal keratitis with ocular demodicosis ends in penetrating keratoplasty and unstable course. Central corneal melting, corneal opacity, and blepharitis with meibomian gland dysfunction were noted in the right eye of case No.2 (A). Stromal melting progressed to descemetocele later, complicated with geographic ulcer (B). Triple procedure (PK, ECCE, PCIOL) was performed (C) for impending corneal perforation and mature cataract. Neurotrophic keratitis was observed in the left eye of case No.3 (D). Triple procedure (PK, ECCE, PCIOL) was performed for persistent epithelial defect and his poor vision (E). Post-PK graft rejection with recurrent geographic ulcer developed 3 years later (F and G). Graft edema persisted for 7 months and resolved dramatically after initiating mite-eradicating therapy (H).
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case_images: A 67-year-old male with diabetes mellitus (DM) was diagnosed as neurotrophic keratitis with persistent corneal defect in his left eye for several months (Figure 1D), which improved after amniotic membrane transplantation (AMT). UCVA from counting finger (CF) at 100 cm to 20/100 was noted in his left eye after triple procedure (Figure 1E). Unfortunately, graft rejection with recurrent geographic ulcer (Figure 1F-G) developed in the same eye 3 years later. Furthermore, the lesions did not respond well to antiviral agents, steroid, and artificial tears for 7 months until ocular demodicosis was identified and intensively treated (Figure 1H).
case_images: PMC7767725_02
case_images: HSV stromal keratitis with ocular demodicosis ends in penetrating keratoplasty and unstable course. Central corneal melting, corneal opacity, and blepharitis with meibomian gland dysfunction were noted in the right eye of case No.2 (A). Stromal melting progressed to descemetocele later, complicated with geographic ulcer (B). Triple procedure (PK, ECCE, PCIOL) was performed (C) for impending corneal perforation and mature cataract. Neurotrophic keratitis was observed in the left eye of case No.3 (D). Triple procedure (PK, ECCE, PCIOL) was performed for persistent epithelial defect and his poor vision (E). Post-PK graft rejection with recurrent geographic ulcer developed 3 years later (F and G). Graft edema persisted for 7 months and resolved dramatically after initiating mite-eradicating therapy (H).
case_images: OPTH-14-4469-g0001.jpg
case_images: PMC7767725_02_OPTH-14-4469-g0001.jpg
case_images: f0001
case_images: A 67-year-old male with diabetes mellitus (DM) was diagnosed as neurotrophic keratitis with persistent corneal defect in his left eye for several months (Figure 1D), which improved after amniotic membrane transplantation (AMT). UCVA from counting finger (CF) at 100 cm to 20/100 was noted in his left eye after triple procedure (Figure 1E). Unfortunately, graft rejection with recurrent geographic ulcer (Figure 1F-G) developed in the same eye 3 years later. Furthermore, the lesions did not respond well to antiviral agents, steroid, and artificial tears for 7 months until ocular demodicosis was identified and intensively treated (Figure 1H).
case_images: PMC7767725_03
case_images: Clinical presentation of HSV stromal keratitis with ocular demodicosis. Geographic corneal ulcer with stromal melting was found in the right eye of case No. 5. (A) Healing epithelial defect under treatment was noted at first (B). Unfortunately, stromal melting progressed to perforation (C); meanwhile, ocular demodicosis was found. More stable condition was established after proper treatment for ocular demodicosis (D). Corneal opacity, cornea thinning, and mutton fat keratic precipitates were shown in the right eye of case No. 8 (E and F). Good response to mite-eradicating therapy with improved visual acuity and clinical appearance was noted (G). Diffuse cylindrical dandruff over the root of eyelashes was identified (black arrowhead) (H).
case_images: OPTH-14-4469-g0002.jpg
case_images: PMC7767725_04_OPTH-14-4469-g0002.jpg
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case_images: Corneal opacity with thinning and mutton-fat KPs (Figure 2E-F) were found. Bilateral lid margins showed diffuse CDs with confirmed ocular demodicosis on epilated lashes (Figure 2H). After 3 weeks of antiherpetic and anti-Demodex treatment, the ocular surface condition became stable (Figure 2G) and his UCVA improved to 20/350.
case_images: PMC7767725_04
case_images: Clinical presentation of HSV stromal keratitis with ocular demodicosis. Geographic corneal ulcer with stromal melting was found in the right eye of case No. 5. (A) Healing epithelial defect under treatment was noted at first (B). Unfortunately, stromal melting progressed to perforation (C); meanwhile, ocular demodicosis was found. More stable condition was established after proper treatment for ocular demodicosis (D). Corneal opacity, cornea thinning, and mutton fat keratic precipitates were shown in the right eye of case No. 8 (E and F). Good response to mite-eradicating therapy with improved visual acuity and clinical appearance was noted (G). Diffuse cylindrical dandruff over the root of eyelashes was identified (black arrowhead) (H).
case_images: OPTH-14-4469-g0002.jpg
case_images: PMC7767725_04_OPTH-14-4469-g0002.jpg
case_images: f0002
case_images: Corneal opacity with thinning and mutton-fat KPs (Figure 2E-F) were found. Bilateral lid margins showed diffuse CDs with confirmed ocular demodicosis on epilated lashes (Figure 2H). After 3 weeks of antiherpetic and anti-Demodex treatment, the ocular surface condition became stable (Figure 2G) and his UCVA improved to 20/350.
case_images: PMC7767725_05
case_images: Recurrent localized HSV stromal keratitis complicated with ocular demodicosis. Stromal edema with localized circumferential opaque ring at superonasal area in the right eye of case No.9. (A) The lesion cleared up after anti-herpetic agents. (B) Recurrent HSV episode at the same area of the cornea was found, complicated with ocular demodicosis (black arrowheads; D,E) (C-F). No recurrence of herpes simplex keratitis was noted after proper treatment of ocular demodicosis (G and H).
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case_images: Corneal stromal infiltration with a localized circumferential opaque ring at the supero-nasal area of the right cornea, superficial punctate keratitis, KPs, and corneal hypoesthesia (Figure 3A) were revealed. The cornea cleared up (Figure 3B) soon within three weeks and his UCVA improved to 20/25 OD. However, recurrent HSV keratitis at the same quadrant of the cornea was noted, complicated with ocular demodicosis 25 months later (Figure 3C-F). Decreased CDs on the eyelashes and clear-up of the cornea were noted 2 weeks later (Figure 3G and H).
case_images: PMC7767725_06
case_images: HSV stromal keratitis with refractory uveitis was controlled after initiating mite eradicating agents. Circumferential immune ring and keratic precipitates were found in the right eye of case No. 1 (A and B). Corneal condition improved after anti-herpetic treatment (C). However, elevated intraocular pressure persisted and did not resolve until initiating mite-eradicating eyelid scrub. Cylindrical dandruff was found over the root of the eyelashes (black arrowheads) (D). Corneal dendritic ulcer and peripheral pannus was noted at temporo-inferior area in the left eye of patient No. 6 (E). Neurotrophic keratitis developed later (F) and five episodes of HSV uveitis with keratic precipitates (G) occurred in the following 2 years. No recurrent HSV infection was noted after managing the Demodex infestation (H).
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case_images: At presentation, ocular examination revealed dendritic ulcer in the left eye (Figure 4E), which resolved within 1 week after anti-herpetic treatment. Seven weeks later, an episode of neurotrophic HSV keratitis with superimposed S. epidermidis infection (Figure 4F) developed in the left eye. Five episodes of HSV uveitis with KPs (Figure 4G) waxed and waned during the following 2 years. No recurrent HSV infection (Figure 4H) was noted during the 6-month follow-up after treatment of ocular demodicosis.
case_images: PMC7767725_07
case_images: HSV stromal keratitis with refractory uveitis was controlled after initiating mite eradicating agents. Circumferential immune ring and keratic precipitates were found in the right eye of case No. 1 (A and B). Corneal condition improved after anti-herpetic treatment (C). However, elevated intraocular pressure persisted and did not resolve until initiating mite-eradicating eyelid scrub. Cylindrical dandruff was found over the root of the eyelashes (black arrowheads) (D). Corneal dendritic ulcer and peripheral pannus was noted at temporo-inferior area in the left eye of patient No. 6 (E). Neurotrophic keratitis developed later (F) and five episodes of HSV uveitis with keratic precipitates (G) occurred in the following 2 years. No recurrent HSV infection was noted after managing the Demodex infestation (H).
case_images: OPTH-14-4469-g0004.jpg
case_images: PMC7767725_07_OPTH-14-4469-g0004.jpg
case_images: f0004
case_images: At presentation, ocular examination revealed dendritic ulcer in the left eye (Figure 4E), which resolved within 1 week after anti-herpetic treatment. Seven weeks later, an episode of neurotrophic HSV keratitis with superimposed S. epidermidis infection (Figure 4F) developed in the left eye. Five episodes of HSV uveitis with KPs (Figure 4G) waxed and waned during the following 2 years. No recurrent HSV infection (Figure 4H) was noted during the 6-month follow-up after treatment of ocular demodicosis.
case_images: PMC7767725_08
case_images: Demodex blepharitis demonstrated in patients with episcleritis/uveitis or atopy. Episcleritis in the right eye and uveitis in both eyes were found in patient No.11 (A). Uveitis frequently flared up and did not resolve until treatment of Demodex blepharitis which is confirmed under microscopic examination (B-D). External appearance of patient No. 7 with atopic dermatitis (E). Disciform keratitis in the left eye was shown at presentation (F). Several episodes of recurrent herpes simplex keratitis with branching dendritic lesions were recorded (G), and keratic precipitates (H) were noted during follow-up examination.
case_images: OPTH-14-4469-g0005.jpg
case_images: PMC7767725_09_OPTH-14-4469-g0005.jpg
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case_images: Atopic dermatitis had been diagnosed before (Figure 5E). The adjacent conjunctiva showed inflammation due to atopic conjunctivitis (Figure 5F). However, several episodes of recurrent HSV keratitis were noted with a persistent circumferential immune ring, branching dendritic lesions (Figure 5G), and endothelial KPs (Figure 5H) during follow-up.
case_images: PMC7767725_09
case_images: Demodex blepharitis demonstrated in patients with episcleritis/uveitis or atopy. Episcleritis in the right eye and uveitis in both eyes were found in patient No.11 (A). Uveitis frequently flared up and did not resolve until treatment of Demodex blepharitis which is confirmed under microscopic examination (B-D). External appearance of patient No. 7 with atopic dermatitis (E). Disciform keratitis in the left eye was shown at presentation (F). Several episodes of recurrent herpes simplex keratitis with branching dendritic lesions were recorded (G), and keratic precipitates (H) were noted during follow-up examination.
case_images: OPTH-14-4469-g0005.jpg
case_images: PMC7767725_09_OPTH-14-4469-g0005.jpg
case_images: f0005
case_images: Atopic dermatitis had been diagnosed before (Figure 5E). The adjacent conjunctiva showed inflammation due to atopic conjunctivitis (Figure 5F). However, several episodes of recurrent HSV keratitis were noted with a persistent circumferential immune ring, branching dendritic lesions (Figure 5G), and endothelial KPs (Figure 5H) during follow-up.
case_images: PMC7767725_10
case_images: Patterns of herpes zoster ophthalmicus with comorbidity of ocular demodicosis. Phymatous rosacea and herpes zoster ophthalmicus were found in patient No. 22 (A). At the same time, herpes zoster keratitis (B) complicated with Demodex infestation showing cylindrical dandruff and telangiectasia over lid margin, was presented (C). Appearance of herpes zoster infection in patient No. 23 (D). Typical meibomian gland dysfunction, telangiectasia, and blepharitis over lid margin were noticed (E and F). Appearance of herpes zoster infection over forehead and periorbita of patient No. 24 (G). Demodex blepharitis with cylindrical dandruff and telangiectasia was revealed over lid margin (H and I).
case_images: OPTH-14-4469-g0006.jpg
case_images: PMC7767725_12_OPTH-14-4469-g0006.jpg
case_images: f0006
case_images: He had hepatitis B and herpes zoster infection with vesicular eruption over his right forehead (Figure 6G). Diffuse CDs on eyelashes and telangiectatic lid margin were noted as well (Figure 6H and I), with microscopically confirmed Demodex mites.
case_images: PMC7767725_11
case_images: Patterns of herpes zoster ophthalmicus with comorbidity of ocular demodicosis. Phymatous rosacea and herpes zoster ophthalmicus were found in patient No. 22 (A). At the same time, herpes zoster keratitis (B) complicated with Demodex infestation showing cylindrical dandruff and telangiectasia over lid margin, was presented (C). Appearance of herpes zoster infection in patient No. 23 (D). Typical meibomian gland dysfunction, telangiectasia, and blepharitis over lid margin were noticed (E and F). Appearance of herpes zoster infection over forehead and periorbita of patient No. 24 (G). Demodex blepharitis with cylindrical dandruff and telangiectasia was revealed over lid margin (H and I).
case_images: OPTH-14-4469-g0006.jpg
case_images: PMC7767725_12_OPTH-14-4469-g0006.jpg
case_images: f0006
case_images: He had hepatitis B and herpes zoster infection with vesicular eruption over his right forehead (Figure 6G). Diffuse CDs on eyelashes and telangiectatic lid margin were noted as well (Figure 6H and I), with microscopically confirmed Demodex mites.
case_images: PMC7767725_12
case_images: Patterns of herpes zoster ophthalmicus with comorbidity of ocular demodicosis. Phymatous rosacea and herpes zoster ophthalmicus were found in patient No. 22 (A). At the same time, herpes zoster keratitis (B) complicated with Demodex infestation showing cylindrical dandruff and telangiectasia over lid margin, was presented (C). Appearance of herpes zoster infection in patient No. 23 (D). Typical meibomian gland dysfunction, telangiectasia, and blepharitis over lid margin were noticed (E and F). Appearance of herpes zoster infection over forehead and periorbita of patient No. 24 (G). Demodex blepharitis with cylindrical dandruff and telangiectasia was revealed over lid margin (H and I).
case_images: OPTH-14-4469-g0006.jpg
case_images: PMC7767725_12_OPTH-14-4469-g0006.jpg
case_images: f0006
case_images: He had hepatitis B and herpes zoster infection with vesicular eruption over his right forehead (Figure 6G). Diffuse CDs on eyelashes and telangiectatic lid margin were noted as well (Figure 6H and I), with microscopically confirmed Demodex mites.