2. INTRODUCTION
◦ CAUSATIVE ORGANISM: HERPES SIMPLEX VIRUS (HSV-1)
◦ AS MANY AS 60% OF CORNEAL ULCERS IN DEVELOPING COUNTRIES MAY BE THE RESULT OF
HSV
◦ IT HAS VARIED MANIFESTATIONS: EPITHELIAL, STROMAL, ENDOTHELIAL(DISCIFORM)
◦ IT HAS TWO FORMS OF INFESTATION: PRIMARY INFECTION AND SECONDARY INFECTION
3. CLINICAL INFESTATIONS
◦ PRIMARY INFECTION :
◦ OCCURS IN CHILDHOOD AND IS SPREAD BY DROPLET TRANSMISSION
◦ CLINICAL FEATURE :
◦ A. SEVERE FOLLICULAR KERATOCONJUNCTIVITIS
◦ B. VESICULAR BLEPHARITIS
◦ TREATMENT:
◦ USUALLY, SELF LIMITING
◦ IF NECESSARY, INVOLVES TOPICAL ACYCLOVIR OINTMENT(3%) FOR THE EYE AND/OR CREAM FOR
SKIN LESIONS AND OCCASIONALLY ORAL ANTIVIRALS.
4. ◦ORAL ANTIVIRALS PREFERRED ARE :
◦ ACYCLOVIR 200–400 MG FIVE TIMES A DAY,
◦ VALACICLOVIR 500 MG ONCE DAILY,
◦ FAMCICLOVIR.
5.
6. CLINICAL INFESTATIONS
◦ RECURRENT INFECTION: OCCURS AS FOLLOWS
◦ AFTER PRIMARY INFECTION THE VIRUS IS CARRIED TO THE SENSORY GANGLION FOR THAT
DERMATOME (E.G. TRIGEMINAL GANGLION) WHERE LATENT INFECTION IS ESTABLISHED.
◦ SUBCLINICAL REACTIVATION CAN PERIODICALLY OCCUR, DURING WHICH HSV IS SHED AND
PATIENTS ARE CONTAGIOUS.
◦ CLINICAL REACTIVATION: A VARIETY OF STRESS FACTORS SUCH AS FEVER, HORMONAL
CHANGE, ULTRAVIOLET RADIATION, TRAUMA, OR TRIGEMINAL INJURY MAY CAUSE CLINICAL
REACTIVATION
◦ IT AFFECTS THE CORNEA MORE THAN THE CONJUNCTIVA
7. MANIFESTATIONS
◦ EPITHELIAL KERATITIS:
◦ SYMPTOMS: Mild–moderate discomfort, redness, photophobia, watering, blurred vision
◦ SIGNS:
◦ REDUCED VISUAL ACUITY
◦ SUPERFICIAL PUNCTATE KERATITIS
◦ DENDRITIC ULCERS, MOST FREQUENT LOCATED CENTRALLY, STAINED WITH FLOURSCEIN
◦ THE VIRUS-LADEN CELLS AT THE MARGIN OF THE ULCER STAIN WITH ROSE BENGAL
◦ GEOGRAPHICAL ULCER
◦ CORNEAL SENSATION IS REDUCED
◦ MILD ASSOCIATED SUBEPITHELIAL HAZE
8.
9. ◦ EPITHELIAL KERATITIS:
◦ INVESTIGATIONS:
◦ Pre-treatment scrapings can be sent in a viral transport medium for culture
◦ PCR and immunocytochemistry are also available
◦ Giemsa staining shows multinucleated giant cells
◦ FLUORESCEIN stain: The branches of the DENDRITIC ulcer have characteristic terminal buds and its bed
stains well with fluorescein. DENDRITIC ULCERS ARE PATHOGNOMIC TO HSV KERATITIS.
◦ ROSE-BENGAL stain: The virus-laden cells at the margin of the ulcer stain with Rose Bengal
◦ TREATMENT:
◦ TOPICAL: ACYCLOVIR 3% OINTMENT /GANCICLOVIR 0.15% GEL
◦ DEBRIDEMENT WITH COTTON BUD
◦ ORAL ANTIVIRAL DRUGS: ACYCLOVIR (200-400 mg) 5 TIMES A DAY FOR 5 – 10 DAYS
◦ CYCLOPLEGICS CAN BE USED TO RELIEVE DISCOMFORT: 1% HOMATROPINE
◦ TOPICAL STEROIDS ARE NOT USED AS THEY MAY CAUSE CORNEAL PERFORATION.
10. MANIFESTATIONS
◦ STROMAL KERATITIS:
◦ IMMUNE-MEDIATED INFLAMMATION IS LIKELY TO PLAY A SIGNIFICANT ROLE
◦ HENCE RESEMBLES LIKE ARTHUS REACTION (TYPE III HYPERSENSITIVITY REACTION) .
◦ SYMPTOMS: redness, photophobia, blurred vision, pain
◦ SIGNS:
◦ STROMAL NECROSIS AND MELTING, OFTEN WITH OPACIFICATION
◦ ANTERIOR UVEITIS WITH KERATIC PRECIPITATES UNDERLYING THE AREA OF ACTIVE STROMAL INFILTRATION
◦ AN EPITHELIAL DEFECT MAY BE PRESENT.
◦ PROGRESSION TO SCARRING, VASCULARIZATION AND LIPID DEPOSITION IS COMMON
11.
12. ◦ STROMAL KERATITIS:
◦ TREATMENT:
◦ COMBINATION OF TOPICAL STEROIDS, TOPICAL ANTIVIRAL DRUGS AND
CYCLOPLEGICS
◦ TOPICAL STEROIDS (PREDNISOLONE 1% OR DEXAMETHASONE 0.1%) WITH
ANTIVIRAL COVER, BOTH FOUR TIMES DAILY.
◦ SUBSEQUENTLY, PREDNISOLONE 0.5% ONCE DAILY IS USUALLY A SAFE DOSE AT
WHICH TO STOP TOPICAL ANTIVIRAL COVER
◦ ORAL STEROIDS ARE SOMETIMES USED IN SEVERE STROMAL INFLAMMATION
◦ ORAL ANTIVIRAL TREATMENT MAY BE HELPFUL WHEN ADDED UP WITH ANTIVIRAL
AGENTS AND CORTICOSTEROIDS.
13. MANIFESTATIONS
◦ DISCIFORM KERATITIS:
◦ ALSO CALLED ENDOTHELIITIS
◦ INFLAMMATION IS LIMITED TO THE CORNEAL ENDOTHELIUM WITH KERATIC PRECIPITATES AND CORNEAL EDEMA AND
DESCEMET’S FOLDS.
◦ SYMPTOMS: Blurred vision of gradual onset and may associate with haloes, mild discomfort and redness
◦ SIGNS:
• CENTRAL ZONE OF STROMAL OEDEMA, OFTEN WITH OVERLYING EPITHELIAL OEDEMA
• LARGE (GRANULOMATOUS) KERATIC PRECIPITATES
• DESCEMET'S FOLDS.
• WESSELY IMMUNE RING OF DEEP STROMAL HAZE (MIMICS TO THE FUNGAL CORNEAL ULCER)
• REDUCED CORNEAL SENSATION.
14.
15. ◦DISCIFORM KERATITIS:
◦ INVESTIGATIONS:
◦ PRE-TREATMENT SCRAPINGS CAN BE SENT IN A VIRAL TRANSPORT MEDIUM FOR CULTURE
◦ TISSUE BIOPSY
◦ IMMUNOFLUORESCENCE
◦ TREATMENT:
◦ COMBINATION OF TOPICAL STEROIDS, TOPICAL ANTIVIRAL DRUGS AND CYCLOPLEGICS
◦ TOPICAL STEROIDS (PREDNISOLONE 1% OR DEXAMETHASONE 0.1%) WITH ANTIVIRAL COVER, BOTH FOUR
TIMES DAILY.
◦ SUBSEQUENTLY, PREDNISOLONE 0.5% ONCE DAILY IS USUALLY A SAFE DOSE AT WHICH TO STOP TOPICAL
ANTIVIRAL COVER
◦ ORAL STEROIDS ARE SOMETIMES USED IN SEVERE STROMAL INFLAMMATION
◦ ORAL ANTIVIRAL TREATMENT MAY BE HELPFUL WHEN ADDED UP WITH TOPICAL ANTIVIRAL AGENTS AND
CORTICOSTEROIDS.
16. COMPLICATIONS:
◦ SECONDARY INFECTION: HERPETIC EYE DISEASE IS A MAJOR PREDISPOSING FACTOR FOR
MICROBIAL KERATITIS.
◦ GLAUCOMA SECONDARY TO INFLAMMATION OR CHRONIC STEROID USE MAY PROGRESS
UNDETECTED.
◦ CATARACT: SECONDARY TO INFLAMMATION OR PROLONGED STEROID USE.
◦ IRIS ATROPHY SECONDARY TO KERATO-UVEITIS
17.
18. PROPHYLAXIS
◦ Long-term oral aciclovir reduces the rate of recurrence of epithelial and stromal keratitis
by about 50%
◦ Oral valaciclovir (500 mg once daily) or famciclovir are alternatives that are probably as effective
as aciclovir, require less frequent dosing and may be better tolerated.
◦ Topical. Oral prophylaxis tends to be preferred to long-term topical administration as epithelial
toxicity may occur
19. BIBLIOGRAPHY
◦ PARSONS’ DISEASES OF THE EYE 23RD ED.
◦ KANSKI’S CLINICAL OPHTHALMOLOGY A SYSTEMATIC APPROACH 9TH ED.
◦ eyewiki.aao.org.
