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Herpes simplex keratitis; dendritic keratitis
Epidemiology:
- most frequent cause of corneal blindness in the United States
- most common cause of infectious blindness in the Western world
Pathology:
- small, raised, clear vesicles on the corneal epithelium early in the disease
- corneal ulcers (dendritic ulcers) most common presentation
- linear branching pattern with terminal bulbs, swollen epithelial borders, central ulceration through the basement membrane
- necrotizing stromal keratitis
- dense stromal infiltrate, ulceration, & necrosis
- immune stromal keratitis
- focal, multifocal, or diffuse cellular infiltrates
- immune rings
- neovascularization
- ghost vessels at any level of the cornea
- endotheliitis
- keratic precipitates
- overlying stromal & epithelial edema
- absence of stromal infiltrate or neovascularization
- mild to moderate iritis (common)
Clinical manifestations:
- eye pain
- photophobia
- blurred vision
- tearing
- red eye
Laboratory:
- scrapings of the corneal or skin lesions
- Giemsa stain: multinucleated giant cells
- Papanicolaou stain:
- intranuclear eosinophilic inclusion bodies
- viral culture
- immunohistochemistry looking for viral antigens
- Herpes simplex virus DNA
Management:
- most cases resolve spontaneously within 3 weeks
- rationale for treatment is to minimize stromal damage & scarring
- epithelial debridement to remove infectious virus & viral antigens that may induce stromal keratitis
- antiviral therapy, topical or oral, is effective
- trifluridine ophthalmic solution 1% (Viroptic)
- valacyclovir (Valtrex)
- acyclovir
- ganciclovir ophthalmic gel 0.15% (Zirgan, Vitrasert)
- topical glucocorticoids may reduce inflammatory response [1]
- months of therapy may be required
- inflammation may reccur with steroid withdrawal
- prognosis is generally favorable with aggressive treatment
Related
Herpes simplex (HSV) or Herpes hominis
General
Herpesvirus eye infection
keratitis
References
- Wang JC and Roy H
eMedicine: Herpes Simplex Keratitis.
http://emedicine.medscape.com/article/1194268-overview