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
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
Image from Rajan Eye Care Hospital
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