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Herpes Simplex Keratitis

Herpes Simplex Keratitis is a common and serious eye infection caused by the Herpes Simplex Virus (HSV). It occurs when the dormant virus reactivates from sensory ganglia and infects the cornea. Clinical presentations include conjunctivitis, punctate epithelial lesions, dendritic ulcers, geographic ulcers, stromal keratitis, and endotheliitis. Treatment involves antiviral ointments, cycloplegics, and occasionally systemic antivirals. Steroids are only used for immune-mediated disciform keratitis and endotheliitis to avoid worsening the infection. Surgery may be needed for severe cases involving corneal scarring. Recognizing the various presentations is important for proper

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599 views20 pages

Herpes Simplex Keratitis

Herpes Simplex Keratitis is a common and serious eye infection caused by the Herpes Simplex Virus (HSV). It occurs when the dormant virus reactivates from sensory ganglia and infects the cornea. Clinical presentations include conjunctivitis, punctate epithelial lesions, dendritic ulcers, geographic ulcers, stromal keratitis, and endotheliitis. Treatment involves antiviral ointments, cycloplegics, and occasionally systemic antivirals. Steroids are only used for immune-mediated disciform keratitis and endotheliitis to avoid worsening the infection. Surgery may be needed for severe cases involving corneal scarring. Recognizing the various presentations is important for proper

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riskhapangestika
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Herpes Simplex Keratitis

Fatma Asyari MBBS, SpM(K)


INOIIS , AINI

CME ophth Sby July 21 2019 1


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

CME ophth Sby July 21 2019 2


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

CME ophth Sby July 21 2019 3


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

CME ophth Sby July 21 2019 4


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
CME ophth Sby July 21 2019 5
Viral conjunctivitis
Adenovirus
enterovirus
herpes virus

Follicles
pseudomembrane

CME ophth Sby July 21 2019 6


Viral conjunctivitis

filaments

pseudomembrane

CME ophth Sby July 21 2019 7


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
CME ophth Sby July 21 2019 9
KPS DD/ epitheliopathy

CME ophth Sby July 21 2019 10


Dendritic keratitis
Characteristic lesion

• reactivation of a latent virus


• Initially punctate lesions, coalescing
into dendritiform pattern
• reduced corneal sensitivity
CME ophth Sby July 21 2019 11
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
CME ophth Sby July 21 2019 12
Necrotizing / Stromal ulceration

• active viral replication


• Decreased corneal
sensation
• Minimal infiltrate ,
relatively transparent
• hypopyon,
• Complication :
uveitis, glaucoma,
cataract, retrocorneal
membrane, rarely
perforation
CME ophth Sby July 21 2019 13
Indolent Ulcer / Metaherpetic keratitis

Rolled -in edge


Persistent epithelial defect
Delayed healing
CME ophth Sby July 21 2019 14
Disciform Keratitis / Endotheliitis

• disc-shaped stromal edema, descemet’s folds


• without infiltration or vascularization
• Diffuse, central, or eccentric
CME ophth Sby July 21 2019 15
Endotheliitis
•

corneal edema, keratic precipitates,


and mild anterior chamber reaction,

CME ophth Sby July 21 2019 16


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)

CME ophth Sby July 21 2019 17


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

CME ophth Sby July 21 2019 18


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

CME ophth Sby July 21 2019 19


Thank you

CME ophth Sby July 21 2019 20

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