HSV Epithelial Keratitis

-Presents with classic dendritic lesions with terminal bulbs

-Recurrent activations within the sensory ganglion can result in cornea scarring, necrosis, and decreased corneal sensation (neurotrophic cornea), all of which can be vision threatening

HISTORY:

-Recurrent red eye, underlying systemic diseases, immunosuppression or immunocompromised state, history of eyelid lesions, history of oral and genital ulcers, and recent infections and vaccinations

SLIT LAMP EXAMINATION:

-Multiple small branching epithelial dendrites on the surface of the cornea

-Often times it first presents as a coarse, punctuate epithelial keratitis, which may be mistaken for a viral keratitis

-The HSV dendrite possesses terminal bulbs that distinguish it from the herpes zoster pseudodendrite and follows the nerve pattern of the cornea

-The clinical diagnosis of HSV may be suggested by the presence of the multiple arborizing dendritic epithelial ulcers with terminal bulbs

-The bed of the ulcer stains with fluorescein, while the swollen corneal epithelium at the edge of the ulcer typically stains with rose bengal

-Several dendrites may also coalesce to form a geographic epithelial ulcer

-Mild conjunctival injection, ciliary flush, mild stromal edema and subepithelial white blood cell infiltration

-Following resolution of the primary infection, a "ghost dendrite" may be visible just beneath the prior area of epithelial ulceration

DIAGNOSIS:

-Usually clinical

-Giemsa stain: intranuclear viral inclusion bodies

-Conjunctival scrapings, impression cytology specimens, and scrapings from vesicular lesions on the skin may be tested by cytology, culture, or PCR for the presence of HSV

-Fluorescent antibody (FAB) testing involving impression cytology using nitrocellulose membrane or a cornea smear

-Tzanck smear: multinucleated giant cells and intranuclear eosinophilic inclusion bodies

MANAGEMENT:

-Topical antiviral - Topical acyclovir (3%) 5times/day for 2 weeks

-Lubricants

-Topical steroids are contraindicated in the presence of active epithelial disease, although cycloplegia drops and topical antibiotics may be added

-If significant stromal scarring: lamellar/ penetrating keratoplasty

COMPLICATIONS:

-Range from epitheliopathy to frank neurotrophic or metaherpetic ulcers

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