Frequency and visual outcomes of herpes simplex keratitis in a Kuwaiti tertiary referral center

Abstract Background: Herpes simplex virus (HSV), a cause of many ocular pathologies, may affect the corneal epithelium, stroma, or endothelium, with the epithelium as the most frequently affected location. We aimed to determine the frequency and visual outcomes of HSV keratitis over a ۱-year period at Farwaniya Hospital, Kuwait. Methods: This prospective observational case series included patients diagnosed with HSV keratitis who presented to the outpatient or eye casualty department between September ۲۰۲۲ and September ۲۰۲۳. Full history, demographic profile, detailed ocular and slit-lamp examinations, and visual acuity assessments were recorded prior to and after treatment. Baseline corneal sensation was assessed in the four corneal quadrants using the cotton wisp test. Results: Of the ۲۲۷ patients who presented with infectious keratitis, ۷۲ (۳۱.۷%) were diagnosed with HSV keratitis. The mean (SD) age was ۴۵.۸۶ (۱۶.۰۶) years, and ۴۸ (۶۶.۷%) patients were male. The subtypes of HSV keratitis were endotheliitis in ۲۷ (۳۷.۵%) patients, dendritic ulcer in ۲۲ (۳۰.۶%), stromal keratitis with ulceration in ۹ (۱۲.۵%) and without ulceration in ۸ (۱۱.۱%), and geographic ulcer in ۶ (۸.۳%). The mean baseline best-corrected distance visual acuity (BCDVA) differed significantly between the HSV keratitis subtypes (P < ۰.۰۰۱). Most patients (n = ۷۰, ۹۷.۲%) had unilateral eye involvement, were treated within ۱ – ۲ weeks, and demonstrated improved BCDVA. Despite the improvement in BCDVA in all HSV keratitis subtypes, a significant difference in the median BCDVA remained after treatment (P < ۰.۰۰۱). Pairwise comparisons revealed a significantly better BCDVA after treatment in eyes with dendritic epithelial ulcers than in eyes with HSV stromal keratitis with ulceration (P = ۰.۰۰۳) or geographic epithelial ulcers (P = ۰.۰۰۵). After treatment, corneal haze and neovascularization were detected in ۵۴ (۷۵.۰%) and ۲۴ (۳۳.۳%) patients, respectively. Conclusions: We detected a substantial frequency of HSV keratitis in one of the governorates of Kuwait, with endotheliitis as the most common manifestation. Timely standard treatment interventions based on valid guidelines resulted in BCDVA improvement in all subtypes of HSV keratitis in our series, indicating the importance of early treatment. However, the BCDVA in eyes with dendritic epithelial ulcers remained substantially better than that in eyes with geographic epithelial ulcers or HSV stromal keratitis with ulceration, signifying the effect of the initial HSV keratitis subtype on visual outcomes. To our knowledge, this is the first study to highlight the frequency of HSV keratitis in a Kuwaiti hospital, and larger-scale research in this region is needed to further understand and manage the condition.