Remission of Multiple Recurrent Dendriform Keratitis in Herpes Zoster Ophthalmicus after Long-term Oral Acyclovir Therapy

Dendriform keratitis is a recurrent sequelae of herpes zoster ophthalmicus (HZO). A 76-year-old immunocompetent Indian male with HZO developed left eye keratouveitis, uveitic glaucoma and superior orbital fissure syndrome. After treatment with intravenous acyclovir for two weeks, there was resolution of cranial nerve palsies. However, he developed 5 recurrences of dendriform keratitis and uveitis over 4.5 years. The spectrum of corneal epithelial lesions included: lacy branching pseudodendrites without true terminal bulbs, thickened grayish epithelium resembling mucous plaque keratitis, and dot-like epithelial erosions or superficial punctate keratopathy in a linear configuration. Each recurrence resolved with treatment with topical acyclovir and steroids. After the 5th recurrence, oral acyclovir 400 mg twice daily was started and continued for 21 months. Thereafter, he remained recurrence-free for 2 years and 9 months to date. Conclusions: Long-term oral acyclovir may have a prophylactic role against recurrent zoster dendriform keratitis and uveitis, suggesting a need for further studies Epithelial recurrences are characterized by a spectrum of pleomorphic patterns.