Herpes Simplex Keratitis

Fatma Asyari MBBS, SpM(K)

INOIIS , AINI

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 Herpes Simplex
Keratitis
• Common , serious, recurrent
• Caused by HSV1
• Primary infection affecting mm , muco- cutaneous
junction
• Dormant state in trigeminal ganglion
• Reactivation to skin , kornea
• Various clinical presentations

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 Primary HS infection
Cold sore or fever blisters at
mucocutaneous junction / aphtous

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Clinical presentations of HSV infections

• Herpes simplex conjunctivitis

• Keratitis punctata superficialis KPS
• Dendritic keratitis
• Amoeboid / Geographic ulcer
• Stromal /disciform keratitis
• Endothelitis
• Trabeculitis
• Herpes simplex Uveitis

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 Viral conjunctivitis
• Adenovirus, enterovirus, herpes virus
• Acute
• Uni/bilateral
• Contagious
• Watering
• No itchy
• Pre-auricular lymphadenopathy
• Hemorrhage ( AHC )
• Pseudo-membrane ( in children )
• Filaments
• Fever , flue
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 Viral conjunctivitis
Adenovirus
enterovirus
herpes virus

Follicles
pseudomembrane

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Viral conjunctivitis

filaments

pseudomembrane

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 Bacterial conjunctivitis
Staphylococcal infection

N. gonorrhoea
Profuse purulent discharge
corneal perforation CME ophth Sby July 21 2019 8
 Epithelial Keratitis

Initially punctate
lesions
Sub-epithelial infiltrate
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KPS DD/ epitheliopathy

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 Dendritic keratitis
Characteristic lesion

• reactivation of a latent virus

• Initially punctate lesions, coalescing
into dendritiform pattern
• reduced corneal sensitivity
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Geographic ulcer
dendritic ---------> ‘amoeboid’ or ‘geographic’ ulcer (
inappropriate steroids use )

• Flat edge , stained with rose bengal

• change shape due to continued viral progression
• Viral cultures will be positive
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 Necrotizing / Stromal ulceration

• active viral replication

• Decreased corneal
sensation
• Minimal infiltrate ,
relatively transparent
• hypopyon,
• Complication :
uveitis, glaucoma,
cataract, retrocorneal
membrane, rarely
perforation
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 Indolent Ulcer / Metaherpetic keratitis

Rolled -in edge

Persistent epithelial defect
Delayed healing
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 Disciform Keratitis / Endotheliitis

• disc-shaped stromal edema, descemet’s folds

• without infiltration or vascularization
• Diffuse, central, or eccentric
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 Endotheliitis
•

corneal edema, keratic precipitates,

and mild anterior chamber reaction,

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 Treatment
• Epithelial debridement
• Gan/Acyclovir topical ointment 5dd
• Cycloplegic : stromal keratitis , endothelitis , uveitis
• Artificial tears as adjuvants, vit A gel
• Systemic antiviral : when severe, immuno-
compromised patients or in HZO infection
• Steroids : in immunological reaction (depending on
the severity of the infection)

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 Surgery

• Conjunctival flap in necrotizing stromal keratitis

• Deep anterior lamellar keratoplasty (DALK) in
recurrent keratitis with corneal scarring
• Amniotic membrane transplantation (AMT)
- helps epithelial lining formation in delayed
healing , Persistent Epithelial Defect PED
- decreases stromal inflammation

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 Message to be keep in mind

• Recognize and keep in mind the various

clinical presentation of HSV Keratitis
• Never give steroids in epithelial infectious HSV
infection except in disciform / endothelitis

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Thank you

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