About Author: Dr. Muhammad Zeeshan Hameed MBBS,FCPS(Resident Eye Surgeon) GMC/DHQ Teachng Hosptal, Gujranwala Pakistan. About Presentation: It covers following topics Introduction Epithelial Keratitis Disciform Keratitis Necrotizing Stromal Keratitis Neurotrophic Keratopathy Herpetic Iridocyclitis Prophylaxis Complications

1. A CASE HISTORY
A 36-year-old female with past history of eye redness 1 year ago and atopy
presents with unilateral (right) eye redness for the past 2 weeks. She has
no history of contact lens wear. One week ago, she saw her primary medical
doctor, who prescribed a topical antibiotic drop (polymyxin/trimethoprim),
which she has been using 4 times a day without relief. Patient denies any
eye trauma to that eye.
Slit-Lamp Examination:
• Unilateral dendritic keratitis without membranes or pseudomembranes.
• Negative for stromal inflammation or anterior chamber or posterior
segment inflammation.
(© 2013 American Academy of Ophthalmology)

2. DIFFERENTIAL DIAGNOSES
• HSV keratitis
• HZV keratitis
• Adenoviral keratitis
• Superficial punctuate keratitis
• Acanthamoeba keratitis
• Healing epithelial defect
• Toxic keratopathy secondary to topical medication
(© 2013 American Academy of Ophthalmology)

3. HERPES SIMPLEX KERATITIS
Dr. Muhammad Zeeshan

4. OUTLINE
• Introduction
• Epithelial Keratitis
• Disciform Keratitis
• Necrotizing Stromal Keratitis
• Neurotrophic Keratopathy
• Herpetic Iridocyclitis
• Prophylaxis
• Complications

5. INTRODUCTION
• Herpetic Eye Disease is the most common infectious cause of
corneal blindness in developed countries
• 60% of corneal ulcers in developing countries
• 10 million people worldwide may have herpetic eye disease.

6. INTRODUCTION
Herpes simplex virus (HSV)
• Enveloped DNA virus
• Two subtypes
a) HSV-1 (above waist)
b) HSV-2 (below waist)

7. INTRODUCTION
PRIMARY INFECTION:
• Mild, self-limited
• In children
• Uncommon before age of 6 months
• Presents with fever, URTI, blepharitis and follicular conjunctivitis
• Treatment is topical Acyclovir ointment (if necessary)

8. INTRODUCTION
RECURRENT INFECTION:
Due to dermatomal distribution of virus, can be
• Sub-Clinical reactivation or
• Clinical reactivation
Rate of Ocular Recurrence after one episode
• 10% at 1 year and
• 50% at 10 years

9. EPITHELIAL KERATITIS
Symptoms:
• Mild–moderate discomfort
• Redness
• Photophobia
• Watering
• Blurred vision

10. EPITHELIAL KERATITIS
Signs: (In chronological order)
a) Swollen opaque epithelial cells (stellate pattern)
b) Central desquamation results in a branching (dendritic) ulcer
c) virus-laden cells at the margin of the ulcer
d) progressive enlargement to a geographical configuration
• Mild sub-epithelial haze

12. EPITHELIAL KERATITIS
TREATMENT:
• Topical
Acyclovir (3%), Ganciclovir (0.15%), Trifluridine
• Debridement
• Oral Antiviral
• Interferone Therapy
• IOP Control, Antibiotics, Cycloplegics

13. DISCIFORM KERATITIS
• The aetiology of disciform keratitis (endotheliitis) is unclear.
Symptoms:
• Blurred vision (± haloes around lights)
• Discomfort and redness
Signs:
a) Epithelial and stromal oedema
b) Surrounding (Wessely) immune ring of deep stromal haze
c) Scarring with vascularization from recurrent disease

15. DISCIFORM KERATITIS
TREATMENT:
• Topical Steroids
Prednisolone (1%) or Dexamethasone (0.1%)
• Topical Antivirals
• Topical Cyclosporine (0.05%)
In presence of epithelial ulceration & to taper off steroids

16. NECROTIZING STROMAL KERATITIS
Due to active viral replication within the stroma (immune-mediated
inflammation)
SIGNS:
• Stromal necrosis and melting
• Anterior uveitis with keratic precipitates
• An epithelial defect may be present
• Progression to scarring, vascularization
TREATMENT:
Similar to disciform keratitis + oral antivirals

18. NEUROTROPHIC KERATOPATHY
Neurotrophic keratopathy (ulceration) is caused by failure of re-
epithelialization
SIGNS:
• A non-healing epithelial defect (after prolonged topical treatment)
• The stroma beneath the defect is grey and opaque and may become
thin.
TREATMENT:
Similar to that of corneal epithelial defects.

20. HERPETIC IRIDOCYCLITIS
• Associated with direct viral activity.
• IOP elevation is due to trabeculitis or steroid-induced.
TREATMENT:
Topical steroids ± oral acyclovir

22. PROPHYLAXIS
• Considered if bilateral or involving an only eye to reduce
recurrences.
• Oral Acyclovir 400mg twice daily
• Famcyclovir, valcyclovir are alternatives.

23. COMPLICATIONS
• Secondary Infection
• Glaucoma
Secondary to inflammation or chronic steroid
• Cataract
Secondary to inflammation or prolonged steroid use.
• Iris atrophy
Secondary to kerato-uveitis

24. THANK YOU