ocular diseases that caused by herpes simplex virus type - 1 from American Academy of Ophthalmology 2016

1. HERPETIC EYE DISEASES
Duhok Eye Hospital
Prepared by: Dr. Niwar Ameen

2. Outlines
 Herpes viruses
 Herpes simplex eye diseases
 Pathogenesis
 Primary ocular infection
 Recurrent ocular infection
 Laboratory evaluation
 Management
 Complications
 Surgical intervention

3. Herpesviruses
 The structure of all HV include:
A core of linear double-strand DNA genome, covered by an
icosahedral protein caspid, an amorphous-appearing
protein and lastly an envelope studded with viral
glycoprotein.
 There are 8 human HVs ; HSV types 1 and 2,VZV, EBV,
CMV and KSHV (Kaposi sarcoma associated
herpesvirus)/Herpesviruses 8.
 All HVs establish latency in their natural hosts with
variability in sites of latency.

4. Herpes Simplex Eye Diseases
 HSV infection is ubiquitous in human; nearly
100% of those above 60 yrs harbor HSV in
their trigeminal ganglia at autopsy.
 Most primary exposure to HSV occurs early in
life, but in developing countries it is being
delayed.
 1/3 world population suffers from recurrent
infection, that is why it is large and worldwide
public health problem.

5. Pathogenesis
 HSV-1 and HSV-2 are antigenically related and may coinfect
the same nerve ganglia.
 HSV-1 more commonly causes infection above the waist
(orofacial and ocular infection), HSV-2 below the waist (genital
infection), but either virus can cause disease in either location.
 Primary HSV-1 infection in humans occurs most commonly on
skin and mucosal surfaces innervated by CNV.
 HSV spread from infected skin and mucosal epithelium via
sensory nerve axons to establish latent infection in associated
sensory nerve ganglia, including trigeminal ganglion.
 Latent infection may occur in the absence of recognized
primary infection.
 Reactivation may follow in any branch of CNV (V1,V2 andV3).

6.  Recurrent infection is caused by reactivation of
the virus in a latently infected sensory ganglion,
transport of the virus down the nerve axon to
sensory nerve endings and subsequent infection
of ocular surface epithelai.
 HSV latency in the cornea remains a
controversial concept as a cause of recurrent
disease.
 Environmental factors such as; psychological
stress, systemic infection, sunlight exposure,
menstrual cycle and CL wear) acting as triggers
for the recurrence of HSV remain controversial,
despite reports of UV- light induced reactivation
of herpes labialis and keratitis, but still these
factors were not confirmed by the Herpetic Eye
Disease Study (HEDS).

7. Primary ocular infection
Clinical presentation
 Typically manifests as a blepharoconjunctivitis.The conj
response is follicular and followed by palpable
preauricular lymph node.
 Vesicles on the skin or eyelid margin are important for Dx
 Patients with primary ocular HSV can develop epithelial
keratitis.
 But stromal keratitis and uveitis are uncommon with
primary ocular infection.

8. Skin Vesicles

9. Eyelid margin ulcer

10. HSV vs. adenovirus ??
 Signs that can be used to distinguish acute primary
HSV infection from that associated with adenovirus:
 1- cutaneous or eyelid margin vesicles, or ulcers on
the bulbar conj (HSV).
 2- dendritic epithelial keratitis (HSV).
 3- conj membranes or pseudomembranes
(adenovirus).
 Laterality is not a reliable feature, because both
conditions can be either unilateral or bilateral,
although adenovirus are commonly bilateral with
delayed involvement of the second eye, unilateral or
asymmetric bilateral, while primary HSV may be
either unilateral (most common) or bilateral.

11. Recurrent Ocular Infection
 Is typically unilateral , only 3% are bilateral.
 The presence of bilateral disease should raise the
question of immune dysfunction e.g., atopic
dermatitis.
 Common presentations of ocular HSV infection:
 1- Blepharoconjunctivitis
 2- Epithelial keratitis
 3- stromal keratitis
 4- iridocyclitis

12. Blepharoconjunctivitis
 Eyelid and/or conj involvement can occur in
patients with recurrent ocular HSV infection.
 It may be clinically indistinguishable from
primary infection

13. Epithelial Keratitis
Clinical Features
 One of the most common presentations of
recurrent HSV infection.
Symptoms:
 1- FB sensation
 2- Light- sensitivity
 3- Redness
 4- Burred vision

14. Signs:
 1- Ciliary flush
 2- Conjunctival injection
 3- Punctate epithelial keratitis
 4- Dendritic epithelial ulcers
 5- Geographic epithelial ulcers (in case use of
Corticosteroids)
 6- Mild stromal edema and subepithelial WBCs
may infiltrate beneath epithelial keratitis
 7- Focal or diffuse reduction in corneal sensation
develops

15. DDx of dendritic epithelial lesion
1. VZV
2. Adenovirus (uncommon)
3. Epithelial regeneration line
4. Neurotrphic keratopathy
5. Soft contact lens wear (thimerosal)
6. Topical medication (antiviral, b-blockers)
7. Acanthamoeba epithelial keratitis
8. Epithelial deposits (iron line, Fabry disease)

16. Dendritic ulcer

17. Geographic ulcer

18. Stromal Keratitis
 It is another presentation of recurrent HSV
ocular infection with greatest visual
morbidity.
 HSV stromal keratitis is the most common
cause of infectious corneal blindness in USA.
 Each episode of stromal keratitis increases
the risk of future episodes.
 Pathogenesis in human remain unknown but
probably is related to the type of stromal
inflammation.

19. Clinical presentation
 Can be nonnecrotizing (interstitial or
disciform) or necrotizing.
Symptoms:
1- gradual onset of blurred vision
2- haloes around lights
3- discomfort and redness milder than epithelial
keratitis.

20. Signs:
 Herpetic interstitial keratitis
1. Unifocal or multifocal interstitial haze or
whitening of the stroma in the absence of
epithelial ulceration.
2. Mild stromal edema, but epithelial edema is
not typical.

21.  Herpetic disciform keratitis which is a primary
endotheliitis.
1. Corneal stromal and epithelial edema in
round or oval distribution
2. KPs underlying the zone of edema
3. Iridocyclitis can be associated
4. Folds in Descement membrane if severe
cases

22. DDx to herpetic Stromal keratitis
1. VZV keratitis
2. Acanthamoeba keratitis
3. Syphilis
4. EBV keratitis
5. Mumps keratitis
6. Sarcoidosis
7. Cogan syndrome

23. Herpetic interstitial keratitis

24. Herpetic disciform keratitis

25. Necrotizing herpetic keratitis
 This is rare form of recurrent HSV infection
 It may be severe, rapidly progress
 Clinically indistinguishable from bacterial or
fungal keratitis.
 Epithelial ulceration is common
 Ulcer do not stain with rose bengal dye.
 Corneal vascularization is common.
 DDx:
1. Bacterial, fungal or acanthamoeba keratitis
2. Retained FB
3. Topical anesthetic abuse

27. Iridocyclitis
 Granulomatous or nongranulomatous
 May accompany stromal keratitis or occur
independently.
 IOP elevation due to trabeculitis
 Patchy iris transillumination defect
 HSV iridocyclitis is suggested by a unilateral
presentation associated with an elevated IOP
with or without focal iris transillumination.

28. Laboratory Evaluation
 The majority of cases are diagnosed on basis of
clinical features.
 Laboratory tests are indicated in complicated cases
when clinical diagnosis is uncertain and in all cases of
suspected neonatal herpes infection.
 In recurrent cases lab tests are of no diagnostic
value.
 Specimen are taken from vesicle, cornea or conj for:
1. Culture
2. Antigen detection (ELISA)
3. PCR

29. Iridocyclitis

30. Management

31. Primary 0cular HSV infection
 is self-limited condition
 Oral antiviral therapy speeds resolution of
signs and symptoms .
 There is no evidence that antiviral therapy at
this stage reduces the likelihood of recurrent
disease.

32. Recurrent Ocular Infection
Blepharoconjunctivitis
 Self-limited
 Antiviral topical to shorten the course of
illness and thus reduce the cornea’s exposure
to the virus.

33. Epithelial keratitis
 Resolve spontaneously but antiviral therapy:
1. Shorten the clinical course
2. Conceivably might reduce;
- associated herpetic neuropathy
- subepithelial scarring
- potential risk of immune-mediated corneal diseases.
 Treatment
1. Debridement (protect adjacent healthy epi, eliminate the antigenic stimulus
to stromal inflammation)
2. Topical antiviral
Topical trifluridine 1% solution / 2hr
Topical acyclovir 3% ointment 5 times / day
Topical should be discontinued within 10-14 day to avoid unnecessary toxicity to
the ocular surface.
3. Oral acyclovir has been reported to be as effective as topical antiviral for
treating epithelial keratitis, and it has the advantage of no ocular toxicity,
for this reason oral therapy is preferred by an increasing number of
physician.
 Topical corticosteroids are contraindicated.

34. Stromal keratitis
 Most important HEDS findings showed that topical
corticosteroids with prophylactic antiviral reduce persistence
or progression of stromal inflammation and shorten the
duration of HSV stromal keratitis, in addition reduce the rate
of recurrent HSV keratitis.
 Long term prophylaxis is recommended for patient with
multiple recurrences of HSV stromal keratitis.
 HEDS protocols for stromal keratitis are as follow:
 Visually significant herpetic interstitial keratitis is treated with:
Topical prednisolone drop 1% 2 hourly accompanied with
prophylactic antiviral drug, either trifluridine 4 times daily or
oral acyclovir 400 mg twice daily.
 Disciform keratitis treatment with
Oral antiviral, like acyclovir 400 mg 5 times daily with topical
corticosteroids.
 Necrotizing herpetic stromal keratitis, oral antiviral such as
acyclovir is preferred with topical corticosteroids twice daily.

35. HSV iridocyclitis
 Topical corticosteroids

36. Complications
1. Epitheliopathy due topical antiviral
2. Neurotrophic keratopathy
3. Persistent bullous keratopathy
4. Corneal scarring and irregular astigmatism
5. Deep corneal stromal vascularization
6. Secondary lipid keratopathy

37. Surgical intervention
 Penetrating keratoplasty (PK) is indicated in
selected patients with visually significant
scarring and astigmatism not correctable by
spectacles or CLs.
 Oral antiviral may improve graft survival by
reducing the risk of HSV recurrence and allow
more liberal use of topical corticosteroids.

38. THANK YOU