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HSV Dendritic Ulcer

Caused by Herpes Simplex Virus, a double stranded DNA virus

Accounts for 50-80% of ocular HSV

Starts as small, raised, intraepithelial vesicles→ vesicles coalesce → linear branching dendrites→ amorphous geographic ulcer

It occurs due to active proliferation of the live virus.


  • Multiple small, linear, branching epithelial dendrites on the corneal epithelium

  • Borders are slightly raised, grayish

  • Central ulceration

  • Possess terminal bulbs and swollen epithelial borders containing the live virus

  • Several dendrites may coalesce to form a geographic epithelial ulcer (especially in immunocompromised patients and inappropriate use of topical steroids)


Rose bengal - stains the devitalized cells and live herpes virus at the edge of the ulcer

Fluorescein - stains the base of the central ulcer

The virus moves from cell to cell, so each lesion develops one cell at a time. There are cells falling out and virus cells filling in giving rise to the linear pattern.

Topical antiviral agents are used in the treatment of HSV dendritic ulcers.

Dendrites should be distinguished from Pseudodendrites

  • Consist of swollen poorly adherent epithelial cells usually seen in the corneal periphery

  • They lack terminal bulbs and dichotomous branching

  • Stain poorly with fluorescein and rose bengal

Secondary to :

Herpes Zoster

Contact lens wear

Recurrent corneal erosions from corneal dystrophies

Image from Rajan Eye Care Hospital

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