Updated: 7/6/2019

Herpes Simplex Keratoconjunctivitis

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Snapshot
  • A 55-year-old woman was referred to an ophthalmologist for eye pain and photophobia. She says her symptoms are associated with visual blurriness and has noticed some "redness" in her sclera. She has a past medical history of hypertension that is adequately managed with diet and exercise and rheumatoid arthritis. She endorses previously having an oral vesicular lesion that self resolved without treatment. Physical examination is notable for ciliary flush of the left eye along with decreased corneal sensation. Slit-lamp examination with a fluorescein stain demonstrates dendritic lesions concerning for herpes simplex virus keratitis.
Introduction
  • Overview
    • an ocular manifestation of herpes simplex virus (HSV)
  • Epidemiology
    • incidence
      • most commonly HSV-1
  • Pathophysiology
    • ocular exposure to viral-laden lesions
      • HSV-1 enters sensory nerve endings and lays dormant in the trigeminal nerve ganglion
        • when reactivated, it travels down the axon and causes lytic damage to ocular tissue
        • HSV-1 also leads to inflamation of the retinal arterioles, causing vaso-occlusion and subsequent rapid necrosis of the retinal tissue
  • Associated conditions
    • HSV-1 infection
  • Prognosis
    • can lead to corneal blindness
Presentation
  • Keratitis
    • symptoms
      • ocular pain
      • visual blurring
      • discharge
      • photophobia
    • physical exam
      • chemosis
      • reduced sensation of the cornea
      • ciliary flush
      • corneal dendritic lesions on slit-lamp examination with fluorescein
  • Conjunctivitis and blepharitis
    • physical exam
      • eyelid inflammation
      • conjunctival inflammation
      • vesicles on the lid margin
Studies
  • Slit-lamp 
    • corneal dendritic lesions on slit-lamp examination with fluorescein 
Differential
  • Contact-lens associated infectious keratitis 
    • differentiating factors
      • a possible complication of contact lens use
      • common organisms
        • Pseudomonas aeruginosa (most common)
        • Staphylococcus
        • Streptococcus
        • Serratia
        • Acanthamoeba
  • Herpes zoster ophthalmicus
    • differentiating factors
      • typically prodromal features of fever, malaise, and headache are present
      • acute and painful vesicular lesions are present via a single dermatome of the trigeminal nerve
Treatment
  • Medical
    • topical or oral antiviral medications 
      • indication
        • first-line treatment
      • comments
        • topical and oral antiviral medications against HSV are equally effective
        • never give steroids
      • medications
        • topical trifluorothymidine
        • topical or oral acyclovir
  • Surgical
    • corneal transplant
      • indication
        • in severe corneal scarring from keratitis
Complications
  • Corneal blindness
  • Acute retinal necrosis
  • Chorioretinitis
 

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(M2.OP.15.14) A 22-year-old woman with no significant past medical history presents with right eye pain, blurry vision, and watery discharge. She had an uncomplicated urinary tract infection for which she has been receiving TMP-SMX. She denies any problems with her left eye. On physical examination, both pupils are equal, round, and reactive to light and accommodation. Intraocular pressure is normal and equal bilaterally. Visual fields are full. However, visual acuity in the right eye is 20/60 compared to 20/20 in the left eye. Slit lamp exam of the left eye reveals the following seen in Figure A. Which of the following is true? Tested Concept

QID: 105380
FIGURES:
1

The treatment is with glucocorticoid drops and the diagnosis is Map-Dot-Fingerprint dystrophy

3%

(1/30)

2

Laboratory and serologic testing should be used to confirm the diagnosis

7%

(2/30)

3

The patient should be admitted for intravenous antibiotics

7%

(2/30)

4

The diagnosis is Stevens-Johnson syndrome and the offending drug should be stopped

7%

(2/30)

5

The patient may be treated with oral acyclovir

67%

(20/30)

M 6 D

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