A 52-year-old male presented with recurrent redness, pain, watering, and occasional eye rubbing for the past 2 years. On examination, the best-corrected visual acuity (BCVA) was 6/24, N8 in the right eye (OD) and 6/6, N6 in the left eye (OS) with normal intraocular pressure in both eyes. OD slit-lamp evaluation revealed a fluorescein-staining, dendrite-like lesion that evolved into ameboid-shaped lesions at varying locations during follow-up, progressing in a circumferential manner. The lesions showed no stromal infiltrate, edema, or vascularization. Corneal sensation in OD was mildly reduced. OS anterior segment was normal. At each follow-up visit, new sites of corneal affliction were observed Fig. 1a–d. Anterior segment OCT (ASOCT) revealed no epithelial hyper-reflectivity Fig. 1e. At baseline, Schirmer’s was 20 mm in OU. At 1 and 3 years, OD measured 30 mm without anesthesia and 10 mm with anesthesia. After 3 years, values dropped to 5 mm with anesthesia, with a TBUT of 4 seconds and low tear meniscus height, indicating worsening aqueous deficiency.Figure 1: (a) Slit-lamp examination of the right eye under cobalt blue filter in diffuse illumination showed an area of fluorescein-stain-positive lesion resembling dendrite form 7-9 o’ clock marked by an arrow. (b) Ameboid-shaped lesions at 1 and 7 o’ clock marked by arrows. (c) Fluorescein stain positive lesion centrally marked by an arrow. (d) Healing lesion at 7 o’ clock. (e) ASOCT image of the right eye shows the absence of epithelial hyper-reflectivityInitial corneal epithelial scraping from the right eye tested negative for HSV-1 and HSV-2 on conventional PCR. Repeat testing with real-time PCR also showed no detectable HSV genome, confirming the absence of herpetic etiology. Histopathology demonstrated multinucleated giant cells, while serum immunoglobulin E (IgE) levels were elevated during symptomatic exacerbations, collectively supporting a diagnosis of presumed allergy-induced migratory epithelial keratitis. After epithelial debridement, a bandage contact lens (BCL) was applied; the patient was started on copious lubricants and topical Gatifloxacin (0.3%) with topical and oral antihistamine. Once serum IgE normalized, no recurrences were observed over 3 years, supporting a possible allergic association. Considering the migratory epithelial pattern, negative HSV testing, supportive histopathology, and synchronous change in IgE levels, this entity is best described as presumed allergy-associated migratory epithelial keratopathy. Discussion Migratory epithelial keratitis, an uncommon entity, often mimics herpetic keratitis because of its recurrent, dendritic pattern. Here, it presented as ameboid lesions with circumferential migration. The absence of stromal involvement, negative PCR, and elevated IgE titer were in favor of allergic etiology. Various patchy, coarse epithelial lesions have been described in the literature, including Advancing Wavelike Epitheliopathy (AWE), corneal dysplasia, carcinoma in situ, squamous cell carcinoma, hereditary benign intraepithelial dyskeratosis, corneal pannus, epithelial keratinization, contact lens-induced keratopathy, superior limbic keratoconjunctivitis, and prominent epithelial basement membrane dystrophy.1 The exact cause of AWE remains unclear.2 Although improvement after allergic control suggests a possible allergic association, alternative explanations—including HSV keratitis with possible false-negative PCR and idiopathic MSCE/AWE spectrum disorders—remain plausible. The clinical features also parallel previously described AWE and MSCE, situating this case within the spectrum of established migratory epithelial disorders. Early recognition is crucial to avoid unnecessary antiviral therapy as proper management of allergic components leads to favorable outcomes. Authors' contributions Dr. Mona Bhargava: Conceptualization Methodology, Definition of intellectual content, manuscript review. Dr. Debasmita Bera: Literature search, data acquisition, manuscript preparation, manuscript review. Dr. Dipsha Chakraborty: Literature search, manuscript preparation and revision. Manuscript has been read and approved by all the authors and the manuscript represents honest work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.
Bhargava et al. (Wed,) studied this question.