Man presents with persistent foreign body sensation and swollen eyelids

A 39-year-old Caucasian man was seen in the Cornea Service at the New England Eye Center with complaints of sore and swollen eyelids and foreign body sensation in both eyes for several months. The patient had a history of recurrent herpes zoster endotheliitis and keratitis in the right eye, which following numerous recurrences had been controlled since the addition of oral acyclovir. History was also positive for dry eye disease, meibomian gland dysfunction, blepharitis, hordeolum in the left lower lid 1 year prior as well as pinguecula in the left eye.Regarding treatment, he was compliant with prophylactic oral acyclovir, flax seed oil and artificial tears, and noncompliant with warm compresses and lid hygiene. He had not responded in the past to AzaSite (azithromycin ophthalmic solution 1%, Akorn), topical erythromycin and oral doxycycline for the treatment of blepharitis. Corneal in vivo confocal microscopy (IVCM) had shown decreased corneal nerve density in the right eye at baseline as a result of prior herpes zoster keratitis with stromal inflammation, which resolved on Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb). The patient was otherwise healthy.