Red eye, pain, foreign body sensation, photophobia, tearing, decreased vision, skin (e.g., eyelid) vesicular rash, history of previous episodes; usually unilateral.
Primary HSV infection is usually not apparent clinically. However, neonatal primary herpes infection is a rare, potentially devastating disease associated with localized skin, eye, or oral infection and severe central nervous system and multiorgan system infection (see 8.9, OPHTHALMIA NEONATORUM [NEWBORN CONJUNCTIVITIS]). Compared to adults, children tend to exhibit more severe disease that may be bilateral, recurrent, and associated with extensive eyelid involvement, multiple corneal/conjunctival dendrites, and a greater degree of secondary corneal scarring and astigmatism. Possible triggers for recurrence include ocular surgery, certain topical medications, fever, stress, menstruation, and upper respiratory tract infection. Infection may be characterized by any or all of the following:
Eyelid/Skin Involvement
Clear vesicles on an erythematous base that progress to crusting, heal without scarring, cross dermatomes, but are typically unilateral (only 10% of primary HSV dermatitis is bilateral).
Conjunctivitis
Conjunctival injection with acute unilateral follicular conjunctivitis, with or without conjunctival dendrites or geographic ulceration.
Epithelial Keratitis
(See Figure 4.15.1.)
May be seen as macropunctate keratitis, dendritic keratitis (a thin, linear, branching epithelial ulceration with club-shaped terminal bulbs at the end of each branch), or a geographic ulcer (a large, amoeba-shaped corneal ulcer with a dendritic edge). The edges of herpetic lesions are heaped up with swollen epithelial cells that stain well with rose bengal or lissamine green; the central ulceration stains well with fluorescein. Corneal sensitivity may be decreased. Subepithelial scars and haze (ghost dendrites) may develop as epithelial dendrites resolve. Epithelial keratitis is considered to be live, replicating viral disease, and treatment is directed accordingly.
4-15.1 Herpes simplex dendritic keratitis.
A true dendrite (branching epithelial ulceration with terminal end-bulbs) is pathognomonic for HSV however there are many similar appearing lesions that should be distinguished:
Stromal Keratitis
Neurotrophic Ulcer
Uveitis
Retinitis
Rare. See 12.8, ACUTE RETINAL NECROSIS.
Blepharoconjunctivitis: Skin/Eyelid/Conjunctivitis
Epithelial Keratitis
Stromal Keratitis Without Epithelial Ulceration
Stromal Keratitis With Epithelial Ulceration
Endothelial Keratitis
Therapeutic dose of topical steroid and therapeutic dose of oral antiviral (see dosing above).
Neurotrophic Ulcer
See 4.6, NEUROTROPHIC KERATOPATHY.
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Chronic use of prophylactic oral antivirals may help prevent subsequent episodes of HSV keratouveitis. |
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