Herpes keratitis

Background

• Most common cause of corneal blindness in US
• Avoid topical steroids to prevent necrotizing stromal keratitis

Clinical Features

Herpes keratitis

• Blurred vision
• Eye pain, photophobia
• Tearing
• Perilimbic injection
• Normal pupil size and intraocular pressure
• Dendritic ulcers with fluorescein

Differential Diagnosis

• Iritis
• Conjunctivitis
• Glaucoma
• UV keratitis
• Herpes zoster
• Contact lens complication
• Fungal keratitis
• Bacterial keratitis
• Interstitial keratitis

Herpes Simplex Virus-1

• Herpes gingivostomatitis
• Herpetic whitlow
• Herpes labialis (cold sore)
• Herpes keratitis
• Eczema herpeticum

Evaluation

Clinical diagnosis with staining and slit lamp exam

• Epithelial disease
  • Infectious epithelial keratitis
    • Corneal vesicles rarely seen; dendritic ulcers form from coalesced corneal vesicles
    • Enlarge into geographic ulcers, with scalloped borders
  • Neurotrophic keratopathy
    • Ulcers more oval, with smooth borders as opposed to geographic ulcers
    • Irregular corneal surface from immune response
    • Decreased corneal sensitivity due to scarring, necrosis

• Stromal keratitis - develops secondarily to in 25% of patients with epithelial disease
  • Necrotizing stromal keratitis - leads to thinning and perforation
  • Immune stromal keratitis - recurrent ocular HSV

• Endotheliitis (disease extending from epithelium to stroma to endothelium)
  • Keratic precipitates
  • Accompanying iritis

Management

• Topical options
  • Ganciclovir optho gel 0.15% 5x daily
  • Cycloplegic for symptoms - Cyclopentolate 1% x1 drop TID, lasts for a day
• Oral acyclovir or valacyclovir may be used alone or in combo with topical
• Avoid topical steroids unless in consult with ophtho (steroids can be started when infectious treatment adequately underway)

Disposition

• Usually self-limiting with most experiencing resolution within 3 wks
• Outpatient consult to ophtho for refractory cases, ulcers needing debridement, and multiple recurrences

References

• Wang, J et al. Herpes Simplex Keratitis. Dec 7 2015. http://emedicine.medscape.com/article/1194268-overview#showall

Authors

Kevin Lu, Ross Donaldson, Claire, Michael O'Brien, MD, Daniel Ostermayer, Neil Young