A 47-year-old male presented with a red, irritated left eye one month after being fit in scleral lenses to address visual disturbances from post-LASIK ectasia. A short course of fluorometholone (FML, Allergan) QID quieted the eye, but it flared on several subsequent lens fits. He was diagnosed with herpes simplex virus (HSV) limbitis/stromal keratitis and started on FML and valacyclovir (Valtrex, GlaxoSmithKline), both BID. 

Limbitis is an active epithelial or stromal HSV lesion occurring at the corneolimbal junction.1 In epithelial disease, marginal lesions often are less dendritic in appearance than central ones, and proximity to blood vessels at the limbus allows white cell infiltration and neovascularization of the underlying corneal stroma. Stromal lesions do not usually occur concurrently with epithelial disease but may result from active viral infection or immune and inflammatory reactions. Immune (non-necrotizing) keratitis occurs in 20% to 60% of eyes with recurrent HSV keratitis and accounts for 90% of recurrent stromal keratitis.2 

Blood vessels may grow into the normally avascular stroma, especially in long-standing disease, and may regress with treatment. Stromal scarring almost always results and can decrease vision significantly, depending on location and severity, requiring treatment of active inflammation. Stromal thinning, fibrosis, pannus and lipid deposits are common.3

At one-month follow up, the patient was refit into a corneal GP/daily disposable piggyback system and treatment tapered to QD as a maintenance dose. He has had no recurrence of disease; however, his ectasia has progressed. He will proceed with crosslinking but will increase his dosing of the prophylactic antiviral prior to the procedure and throughout the postoperative period.

1. Liesegang TJ. Classification of herpes simplex virus keratitis and anterior uveitis. Cornea. 1999;18(2):127-43.
2. Al-Dujaili LJ, Clerkin PP, Clement C, et al. Ocular herpes simplex virus: how are latency, reactivation, recurrent disease and therapy interrelated? Future Microbiol. 2011 Aug;6(8):877–907.
3. Knickelbein JE, Hendricks RL, Charukamnoetkanok P. Management of herpes simplex virus stromal keratitis: an evidence-based review. Surv Ophthalmol. 2009;54(2):226-34.