Herpes Simplex Negative Trabeculitis Responsive to Anti-Viral Mediation: A Case Report

Background: Patient’s that present with unilateral ocular hypertension can create a diagnostic challenge for the clinician. This observational case reports of a patient who initially presented with unilateral eye pain, whose HSV PCR was negative, however still appeared to respond to anti-viral treatment. The patient had a unilateral intraocular pressure spike that only decreased with addition of topical steroid, thus was presumed to be secondary to trabeculitis. Case Presentation: This case reports a healthy 47-year-old male, who initially presented with unilateral eye pain (44 mmHg). The patient’s IOP was unresponsive to pressure-lowering medication, but was eventually normalized with topical steroid. Despite negative PCR sampling of aqueous humor, the patient’s ocular exam and subjective symptoms normalized after a course of acyclovir. Conclusion: This case highlights an unusual presentation of a unilateral IOP spike, which was only responsive to topical steroid, supporting the idea of an inflammatory origin. However, the subsequent development of anterior chamber reaction infers a potential infectious etiology. Although the patient’s HSV PCR was negative, a course of acyclovir did appear to resolve the patient’s inflammation, IOP increase, and subjective symptoms. In this patient, it is not certain if HSV was the causative agent involved. Though even with a negative anterior chamber sample, suspicion for HSV remains high, as the patient appeared to improve with antiviral treatment. This case has significant clinical relevance for the clinician managing unilateral ocular hypertension seemingly resistant to initial pressure-lowering treatment, a somewhat uncommon but not scarce case.