A 70-year-old woman was referred to our office as a glaucoma suspect in the setting of recurrent herpes simplex virus (HSV) epithelial and stromal keratitis of the right eye. The patient had no history of associated uveitis. Primary angle closure was suspected, and she underwent bilateral laser peripheral iridotomies (LPIs). Her medications at presentation included latanoprost at bedtime, a fixed combination of dorzolamide and timolol twice daily, brimonidine twice daily, trifluridine of varying frequency, frequent loteprednol tapers for intermittent corneal stromal involvement, and oral acyclovir 800 mg three times daily.
Although the LPIs succeeded in opening the angles, IOP remained in the mid-20s in the right eye. Optical coherence tomography of the retinal nerve fiber layer showed thinning of the right optic nerve compared to the left, with a corresponding nasal step on the visual field. Because the patient was overwhelmed by the drop regimen and we were concerned about corneal toxicity, we performed selective laser trabeculoplasty (SLT) in an attempt to reduce the medication burden. Unfortunately, the IOP remained unchanged.
Subsequently, the patient underwent trabeculectomy with mitomycin C in the right eye. Approximately 6 months postoperatively, she underwent a full-thickness corneal transplant in the same eye. Ten years later, she maintains a BCVA of 20/40 and an IOP in the upper teens on no glaucoma drops in the right eye. She continues to use loteprednol etabonate ophthalmic ointment 0.5% (Lotemax; Bausch + Lomb) once daily for rejection prophylaxis and takes oral acyclovir 400 mg twice daily to reduce the risk of recurrent HSV.