Viral keratitis is commonly caused by herpes simplex virus types 1 and 2 and varicella zoster virus. HSV keratitis typically presents as dendritic ulcers or geographic ulcers on the cornea. It can also cause stromal keratitis. Varicella zoster virus causes herpes zoster infection which presents with a painful rash that follows dermatomal patterns, and can also lead to keratitis. Adenovirus is another common cause and presents as punctate epithelial keratitis that may develop into nummular opacities. Treatment involves topical antivirals and steroids depending on the type and severity of infection.

1. Viral Keratitis
dr. Frenky R. de Jesus
Nacional Eye Centre
Postgraduate diploma in Ophthalmology
ViralKeratitis
ViralKeratitis

2. Viral Keratitis
dr. Frenky DJ
GEOGRAPHIC ULCERDENDRITIC ULCER
NUMULAR KERATITIS

3. Viral Keratitis
dr. Frenky DJ
Introduction
Viral keratitis is the commonest cause of keratitis in the developed world.
There are two major types of the virus:
• Type I (most common and primarily infects the face), causing "cold sore" or
"fever blister."
• Type II (sexually transmitted form of herpes).
Infective keratitis is suppurative infection of cornea which may be associated
with epithelial defects and or signs of inflammation.
Reactivation including: stress, sun exposure or other UV light exposure (such as
tanning beds), fever, trauma to the body (such as injury or surgery), menstruation,
certain medications.
• Individual layers of the cornea
• All the layers of cornea.

4. Viral Keratitis
dr. Frenky DJ
Viruses Causing Keratitis
DNA Viruses RNA Viruses
HSV Type- 1 Type-2 PICORNA VIRUS
VARICELLA ZOSTER VIRUS ECOVIRUS 70
ADENO VIRUS PARAMYXO VIRUS
CYTOMEGALO VIRUS MEASLES VIRUS
EPSTEIN BARR VIRUS MUMPS VIRUS
VARIOLA ORTHOMYXO VIRUS
VACCINIA INFLUENZA- A,B,C.
MOLLUSCUM CONTAGIOSUM TOGA VIRUS
PAPOVA VIRUS RUBELLA VIRUS

5. Viral Keratitis
dr. Frenky DJ
1. Herpes Simplex Virus
• Is a member of family Herpes Viridae.
• HSV is a large and complex enveloped virus measuring 150-200 nm.
• Direct contact by salivary droplets or fomites from children and adults with
active disease and also of asymptomatic virus shedding carriers.
• Humans are only natural host.
• Two types; HSV-1 & HSV-2.
MODE OF INFECTION
Lips, nose and cornea: HSV-1 (above
abdomen)
(Close contact with patient suffering from
herpes labialis)
Genitals: HSV-2 (below abdomen)
(to eye of neonate through infected genitalia
of mother)

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dr. Frenky DJ
PATHOGENESIS

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dr. Frenky DJ
CLINICAL MANIFESTATION

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dr. Frenky DJ
a. Congenital & Neonatal Ocular Herpes
• Can be: Intrauterine (4%) Peripartum (10%) Post
partum (86%).
• HSV keratitis in a neonate is invariably associated
with conjunctivitis.
• Features; Diffuse microdendritis, serpiginous
epithelial defects or a punctate keratitis.
• Diagnosis; with nonpurulent conjunctivitis or keratitis.
• Treatment;
✴ Topical antivirals (1% Trifluridine ophthalmic solution
or 3% acyclovir ophthalmic ointment) in addition to
✴ Systemic Acyclovir (2 g/day IV every 8 hourly for 14
days).

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dr. Frenky DJ
• Usually occurs in childhood.
• Uncommon during first 6 months of life.
• Mostly infection is subclinical or cause mild
fever, malaise & URTI.
• Ocular manifestation include;
b. Primary Ocular Herpes
✴ Acute follicular conjunctivitis
✴ Keratoconjunctivitis (lymphadenopathy)
✴ Periocular & eyelid skin lesions
•Early involvement of cornea; Diffuse punctate
keratopathy.
•These lesions are mild and self limiting.

10. Viral Keratitis
dr. Frenky DJ
c. Recurrent Ocular Infection

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dr. Frenky DJ
BLEPHARITIS
• Can result from primary infection or recurrent.
• C/F; vesicular lesions involving focal area of
eyelid with surrounding erythema.
• Typical lesion progresses to ulceration crusting
heals without scar, unless secondarily infected.
CONJUNCTIVITIS
•Follicular conjunctivitis, is self limiting
•May progress to keratitis
c. Recurrent Ocular Infection
KERATITIS

12. Viral Keratitis
dr. Frenky DJ
Epithelial involvement
Stromal involvement
Endothelium involvement
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Infectious epithelial keratitis
Neurotrophic keratopathy
Immune Stromal Keratitis
Necrotizing Stromal Keratitis
Endothelitis

13. Viral Keratitis
dr. Frenky DJ
• Caused by reactivation of live virus.
• C/F; pain, photopbobia, thin watery discharge, decrease vision if lesion is
central.
• Earliest epithelial lesion is characterized by corneal epithelial vesicles.
1. DENDRITIC ULCER
• Most common presentation of HSV keratitis.
• Derivative of DENDRON the Greek word for Tree.
• Features: branching linear lesion with terminal buds and swollen opaque
epithelial cells arranged in coarse punctate or stellate pattern that contain live
virus.
• Other associated features; Reduced corneal sensation, Mild subepithelial haze,
Follicular conjunctivitis.
EPITHELIAL INVOLVEMENT
Infectious Epithelial Keratitis

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dr. Frenky DJ
• Following healing there may be persistent punctate epithelial erosion and irregular
epithelium which settle spontaneously.
Dendrites; fluorescein along the length of lesion
Swollen epithelial borders; rose Bengal (devitalized cells)

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dr. Frenky DJ
• An enlarged dendritic ulcer is no longer
linear and is referred as geographic ulcer
(amoeboid)
• Feature; swollen epithelial borders that
contain live virus and scalloped borders.
2. GEOGRAPHIC ULCER

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dr. Frenky DJ
Treatment
Predominantly with nucleosidide analogue that disrupt viral DNA
1. TOPICAL
• Aciclovir 3%
• Ganciclovir 0.15%
• Trifluridine
2. DEBRIDEMENT; for resistant cases
(protects adjacent healthy epithelium and eliminates antigenic stimulus to stromal
inflammation)
3. ORAL ANTIVIRAL THERAPY; Aciclovir 200-400mg
• CYCLOPLEGICS; Homatropine 1%
• Topical ANTIBIOTICS
• Skin lesion; Aciclovir cream

17. Viral Keratitis
dr. Frenky DJ
• Results from active viral diseases.
• It has proximity to limbus with
accompanying blood vessels.
• Features; epithelial lesion,
infiltrates with WBC from nearby
limbal vessels with adjacent limbal
injection, anterior stromal infiltrates
underlying the ulcer.
• More symptomatic due to intense
inflammation.
• Rare and most often confused with
staphylococcal marginal diseases
3. MARGINAL ULCER

18. Viral Keratitis
dr. Frenky DJ
• Arises from impaired corneal innervation combination with decrease tear
secretion.
• Failure of re-epithelization resulting from corneal anaesthesia.
• Features; irregularity of corneal surface. lack of normal corneal lustre.
• Defect is oval in shape with smooth borders, stroma beneath it is grey and
opaque, may become thin
• Ulcer has thickened border formed by heaped up epithelium.
• Complication; stromal scarring, NVZ, necrosis, perforation, secondary
bacterial infection.
Treatment;
Stop all unnecessary topical medications.
- Artificial tears.
- Topical Antibiotics.
- Gentle debridement.
- Bandage contact lens.
- Conjunctival flapping.
- Tarsorrhaphy (Botulinum, Surgical)
Neurotrophic Keratopathy
EPITHELIAL INVOLVEMENT

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dr. Frenky DJ
• Occurs due to active viral replication within stroma, immune mediated
• Characterised by:
- Epithelial defect.
- Stromal necrosis & melting.
- Dense stromal infiltrate.
- Associated Ant. Uveitis with KP’s underlying areas of active stromal
infiltration.
• Complications:
- Corneal thinning & perforation.
- Scarring
- Vascularization
- Lipid deposition.
• Treatment
- Topical Antiviral
- Topical antibiotics & cycloplegics.
- Conjunctival flapping & cyanoacrylate glue in cases of perforation.
STROMAL INVOLVEMENT
1. Necrotizing Stromal Keratitis

20. Viral Keratitis
dr. Frenky DJ
• Found in about 20% of patients with ocular HSV.
• Viral antigen in stroma triggers intra stromal inflammation.
• Overlying epithelium is usually intact.
• Characterised by:
- Stromal infiltration (punctate) - Stromal edema.
- Wessley immune ring
- Stromal neovascularisation
- Lipid keratopathy.
• Complications:
- Disciform keratitis
- Scarring
• Treatment;
- Topical steroids
- Topical Antivirals
- Topical Antibiotics, Lubricants & Cycloplegics. - Oral steroids in severe
cases.
2. Immune Stromal Keratitis
STROMAL INVOLVEMENT

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dr. Frenky DJ
• P a t h o g e n e s i s u n k n o w n , m a y b e
immunologic.
• Classified; 1. Disciform 2. Diffuse 3. Linear
ENDOTHELITIS
• C/F; blurred vision with haloes around
light discomfort redness
• Signs; central zone of stromal oedema,
often with overlying epithelial oedema,
granulomatous KP underlying oedema,
DM folds in severe cases, WESSELY
RING, Decreased corneal sensation.
1. Disciform Endothelitis
ENDOTHELIUM INVOLVEMENT

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dr. Frenky DJ
• Topical steroids with antiviral cover-prednisolone1% or dexamethasone
0.1%
• Monitor IOP
• Cycloplegics for comfort if needed
• With active epithelial lesion; steroid as low as possible, more frequent
antiviral regimen.
• Oral steroids- .
✴ Severe stromal inflammation
✴ Reduce steroid induced IOP elevation
✴ Avoid viral promotion in infectious viral keratitis
• Topical ciclosporin 0.05%
ENDOTHELIUM INVOLVEMENT

23. Viral Keratitis
dr. Frenky DJ
• Scattered KP spread over the entire endothelium
• Stromal oedema involving entire cornea
• Microcystic epithelial oedema
• T/t-topical and systemic; steroids, antivirals
2. Diffuse Endothelitis
3. Linear Endothelitis
• Line of KP from limbus, may be sectoral or circumferential
• Edema present peripheral to line of KP, extending to limbus
• Microcystic epithelial oedema
• T/t-topical and systemic antivirals and corticosteroids
• Corneal decompensation is common
ENDOTHELIUM INVOLVEMENT

24. Viral Keratitis
dr. Frenky DJ
• Varicella zoster virus also referred as human herpes virus type 3.
• Causes; varicella (chickenpox) & herpes zoster (shingles).
• Herpes zoster derives its name from Greek word HERPEIN; to spread, to creep
Zoster; girdle or zone.
• Life time risk of herpes zoster is 10-30%.
2. Herpes Zoster

25. Viral Keratitis
dr. Frenky DJ
• Increasing risk (>70 years)
• Neoplastic diseases
• Immunosuppressive drugs
• Organ transplant recepients
• HIV
• Others; syphilis, TB, malaria, emotional & physical stress.
Risk Factors
Pathogenesis
• Humans are only known natural host to VZV
• Structure; core of double stranded DNA surrounded by icosahedral
nucleocapsid with an outer cell membrane containing glycoproteins,
carbohydrates, lipids.
• This outer envelope helps in attachment and penetration of virus into human.

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dr. Frenky DJ
Pathogenesis

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dr. Frenky DJ
• Painful erythematous areas with a maculopapular rash which respects the
midline.
• Within 24 hours, groups of vesicles appear and these become confluent over
2–4 days.
• Boggy oedema of the upper and lower lids is common and often spreads to
the contralateral side of the face.
• Vesicles pass through a pustular phase crust and dry after 2–3 weeks.
• Large, deep haemorrhagic lesions in immunodeficient patients
• Lesions heal to leave residual skin destruction and depigmented scars
• Zoster sine herpete is shingles without a rash.
Skin Lesions

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dr. Frenky DJ

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dr. Frenky DJ
Oral antiviral;
• Aciclovir (800 mg 5 times/day)
• Newer agents; valaciclovir 1 g TID or famciclovir 250–500 mg TID have more
convenient regimens, are better tolerated and are at least as effective as
Aciclovir..
Intravenous Aciclovir; 5–10 mg/kg TID in encephalitis, and
immunocompromised individuals
Systemic steroids; Prednisolone in tapering doses.
Treatment

30. Viral Keratitis
dr. Frenky DJ
• Causative agent for epidemic keratoconjunctivits
• Caused by serotype 8,19,37
• Highly contagious, via hands and fomites
• Corneal trauma facilitates infection
• Incubation period-8 days
• Symptoms-insidious onset Pain, photophobia, watering, Children may have
fever and lymphadenopathy.
• Associated with-Follicular keratoconjunctivitis, Palpebral oedema,
Preauricular lymphadenopathy (pathognomic), Haemorrhagic conjunctivitis.
3. Adenovirus

31. Viral Keratitis
dr. Frenky DJ
STAGE-1: corneal epithelial vesicle like elevation, 25-30 microns.
STAGE-2: 2-5 days later, lesions coalesce and involve deeper epithelium,
classical epithelial punctate keratitis lesion.
STAGE-3: faint subepithelial infiltrates present beside the punctate keratitis.
STAGE-4: nummular opacities, may be present weeks to month after initial
episode. (residual scarring & visual impairment may occur)

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dr. Frenky DJ
• Treatment-
Artificial tears
Topical vasoconstrictors
Steroids
Cold compress

33. Viral Keratitis
dr. Frenky DJ
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