Herpes simplex virus (HSV) and varicella zoster virus (VZV) are the most common causes of viral keratitis. HSV can cause dendritic ulcers on the cornea from reactivation of the latent virus in the trigeminal ganglia. Symptoms include pain, photophobia, and decreased vision. Treatment involves topical or oral antiviral medication. VZV reactivation in the trigeminal ganglia can also infect the cornea, presenting with punctate keratitis or herpetic ulcers. Severe pain and rash in the skin supplied by the trigeminal nerve help differentiate VZV keratitis.

1. in this article we will discuss viral
keratitis and we will give a short brief
about herpes simplex and zoster
viruses
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2. H e r p e s
s i m p l e x
Definition
Etiology
It is superficial , linear , branching ulcer due to
infection of the cornea by Herpes simplex virus
HSV is an epithelio-tropic virus , found in the trigeminal
ganglia in about 100% of population producing no symptoms .
But when the body resistance decreases , it becomes active
infecting the epithelium causing vesicles .
Precipitating factors
( which activates the virus )
1- fever : common after pneumonia , influenza , common cold … etc.
- Decreased immunity
- Fever activates the virus .
So, hot fomentation not used in treatment .
2- Stress : as in operations , pregnancy , onset of menstruation .
3- Immuno suppressant drugs : local of systemic .
So, cortisone not used in treatment .
4- U.V rays over exposure .
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3. Type 1
responsible for 75% of ocular infection . it
usually affects the oropharyngeal region .
Types of HSV
H e r p e s
s i m p l e x
Type 1
responsible for 25% of ocular infection .
it usually affects the genital region .
The two types are differentiated
by specific antigens
1- primary herpes
2- recurrent infection
• Age : 6 months – 6 years . [ uncommon before 6 months due
to maternal antibodies ]
• Clinical picture :
- lid vesicles - follicular conjunctivitis
- punctuate epithelial lesion ( no stromal lesion )
• Age : 15- 60 years .
The latent virus which is dormant in the Gasserian ( trigeminal )
ganglion is re-activated and travel along the 5th nerve leading to :
- lid vesicles - follicular conjunctivitis
- dendretic ulcer - stromal immune keratitis
- iritis
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4. ‫ر‬USTRIES
clinical picture
sign
symptoms
Their is collection of symptomes accompanied togither that
patiant complain from incloding:
-pain:caused by exposure of nerve endings but not sever due to
hypothesia
-photophobia ,tearing,blepharospasm and redness
-dimention of vision due to affection of epithelium espitially in
centre.
first time HSV infection occurs from 6mounthes to 5 years only
represented by mild fever and upper respiratory tract infection .
Epithelial lesions:
-Dendretic ulcer;branching from ulcer end by bulbs(knobs)
-Geographical ulcer (Ameboid);flaring of ulcer when using steroid
or immunosuppresed patiants.
-Marginal;on edge of cornea.
Rose bengal andlissamine green inhibit PCR detection of HSV
DNA so scraping for PCR should be taken before staining.
Stromal lesion:
-Non necrotizing (disciform) Keratitis;due to Ag-Ab
reaction.
-Necrotizing Keratits;due to viral invasion.
H e r p e s
s i m p l e x
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5. ‫ر‬USTRIES
Treatment of dendritic ulcer
Most cases may resolve spontaneously in 3 weeks
but it is advised to give treatment to minimize
stromal lesion caused by viral antigen.
• topical anti viral:
- Gancyclovir,
- Acyclovir.
- Trifluridine.
- Vidarabine.
- A cycloplegic agent may be added to avoid cilliary spasm.
- Topical treatment has the advantages of being less toxic and
specificity also response usually occur in 2-5 dys and
complete resolution I 2 weeks.
• oral therapy:
- Acyclovir may be used alone orally or with topical drugs
It has the advantage of no ocular toxicity when used orally
It is used rally in pediatric an immuocompromised persons
It is used as long term prophylaxis in recurrent hsv ulcer.
- Vitamin A and C may be used also.
• depridement:
- the use of sharp instruments should be avoided to avoid
cutting bowmans membrane and causing opacity
it should be done by a cotton-tipped applicator and alchoholic
solution of iodine.
• keratoplsty:
if other methods fail.
H e r p e s
s i m p l e x
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6. organism
h e r p s
z o s t e r
clinical picture
treatment
Varicella-zoster virus:
Neurotropic virus
Affect the eye if trigeminal ganglion is
infected with virus:
In naso ciliary nerve affection ... corneal
affection
In frontal nerve affection ... lid affection
sign
symptoms
Red eye
Sever pain (neuralgic pain
Photophobia
Lacrimation
Blepharospasm
Decrease of vision
Vesicle
Cornea:
Punctate keratitis
Herpetic ulcer
Deep keratitis
Corneal anasthesia
their is another sign in lids and sclera a optic nerve :
- HUTCHINSON’S SIGN:
if tip of nose is affected with vesicle we can expect that ehe cornea will
be affected (as tip of nose is supplied by a terminal branch of naso-ciliary
nerve
Rest, Sedative and Analgesic for Pain
Skin lesion:
Local: calamine lotion . Antibiotic Powder
General: Acyclovar tablet(zovirax) 1*4 for 7 days and
Antibiotic(to prevent 2ry infection)
corneal ulcer: Acyclovar mohamedmostafa

7. Differential diagnosis
Diffrantiate it from
1- HSV
2- red eye
3- decrese of vision
h e r p s
z o s t e r
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8. v i r a l
k e r a t i t s
reverence
-Author:
Jim C Wang (王崇安), MD Vitreo-Retinal and Cornea/Anterior Segment
Subspecialist, Department of Ophthalmology, Kaiser Permanente
Fontana Medical Center
- Coauthor(s)
David C Ritterband, MD, FACS Assistant Director of Cornea Service, New
York Eye and Ear Infirmary; Clinical Professor of Ophthalmology, Icahn
School of Medicine at Mount Sinai
- Chief Editor
Hampton Roy, Sr, MD Associate Clinical Professor, Department of
Ophthalmology, University of Arkansas for Medical Sciences
- date: Dec 07, 2015
- web site: medscape.com
1-HSV
- Original article contributed by: Lisa M Nijm
- All contributors: Alex Kozak, Brad H. Feldman, M.D., Lisa Nijm, MD,
Mallika Doss, MD and Vatinee Bunya, MD
- Assigned editor: Vatinee Bunya
- Review: Assigned status Update Pending by Vatinee Bunya, MD on July
4, 2015.
- Original article contributed by: John B. Cason MD
- All contributors: Brad H. Feldman, M.D. and John B. Cason MD
2-HSV
3-HZO
- Herpes Zoster Ophthalmicus
(- Herpes Zoster Virus Ophthalmicus; Ophthalmic Herpes Zoster;
Varicella-Zoster Virus Ophthalmicus)
- By Melvin I. Roat, MD, FACS
- website:http://www.merckmanuals.com/home/eye-disorders/corneal-
disorders/herpes-zoster-ophthalmicus mohamedmostafa

9. the end of the article
thanks
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