Herpes simplex keratitis: Difference between revisions
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*Most common cause of corneal blindness in US | *Most common cause of corneal blindness in US | ||
*Avoid topical steroids to prevent necrotizing stromal keratitis | *Avoid topical steroids to prevent necrotizing stromal keratitis | ||
{{Conjunctivitis DDX}} | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:Herpes simplex geographic corneal ulcer.jpeg|thumbnail|Herpes keratitis]] | [[File:Herpes simplex geographic corneal ulcer.jpeg|thumbnail|Herpes keratitis]] | ||
*Blurred vision | [[File:HSVconjuctivitis.png|thumbnail]] | ||
* | *[[Blurred vision]] | ||
*[[Eye pain]], photophobia | |||
**More pain than with typical conjunctivitis | |||
*Tearing | *Tearing | ||
*Perilimbic injection | *Perilimbic injection | ||
*Normal pupil size and intraocular pressure | *Normal pupil size and [[intraocular pressure]] | ||
*Dendritic ulcers with fluorescein | *Dendritic ulcers with fluorescein | ||
**May also see "geographic ulcers" - amoeba-like ulceration with dendrites at the edges<ref>Go S. Eye Emergencies. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed March 12, 2021. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158§ionid=162273694</ref> | |||
*Severe cases may cause [[uveitis]], [[iritis]] | |||
== | ===[[Slit lamp]]/Fluorescein=== | ||
== | |||
*Epithelial disease | *Epithelial disease | ||
**Infectious epithelial keratitis | **Infectious epithelial keratitis | ||
| Line 34: | Line 27: | ||
***Irregular corneal surface from immune response | ***Irregular corneal surface from immune response | ||
***Decreased corneal sensitivity due to scarring, necrosis | ***Decreased corneal sensitivity due to scarring, necrosis | ||
*Stromal keratitis - develops secondarily to in 25% of patients with epithelial disease | |||
*Stromal keratitis - develops secondarily to in 25% of | |||
**Necrotizing stromal keratitis - leads to thinning and perforation | **Necrotizing stromal keratitis - leads to thinning and perforation | ||
**Immune stromal keratitis - recurrent ocular HSV | **Immune stromal keratitis - recurrent ocular HSV | ||
*Endotheliitis (disease extending from epithelium to stroma to endothelium) | *Endotheliitis (disease extending from epithelium to stroma to endothelium) | ||
**Keratic precipitates | **Keratic precipitates | ||
**Accompanying iritis | **Accompanying iritis | ||
==Differential Diagnosis== | |||
*[[Iritis]] | |||
*[[Conjunctivitis]] | |||
*[[Glaucoma]] | |||
*[[UV keratitis]] | |||
*[[Herpes zoster]] | |||
*[[Contact lens]] complication | |||
*Fungal keratitis | |||
*[[Bacterial keratitis]] | |||
*Interstitial keratitis | |||
{{HSV-1 DDX}} | |||
==Evaluation== | |||
Clinical diagnosis with staining and slit lamp exam | |||
==Management== | ==Management== | ||
*Topical options | *Topical options | ||
**Ganciclovir | **Acyclovir 3% ophthalmic ointment 5x daily | ||
**Cycloplegic for symptoms - Cyclopentolate 1% x1 drop | ***Continued for three days after clearing of corneal lesions | ||
*Oral acyclovir or valacyclovir may be used alone or in combo with topical | **If unavailable, [[Ganciclovir]] ophthalmic gel 0.15% 5x daily | ||
*Avoid topical steroids unless in | **[[Cycloplegic]] for symptoms - [[Cyclopentolate]] 1% x1 drop 3x daily, lasts for a day | ||
*Oral [[acyclovir]] (400mg 5x daily) or [[valacyclovir]] (500mg 3x daily) may be used alone or in combo with topical | |||
**Treatment can be stopped one week after healing of the lesions | |||
*Avoid topical steroids unless in consult with ophtho (steroids can be started when infectious treatment adequately underway) | |||
==Disposition== | ==Disposition== | ||
*Usually self-limiting with most experiencing resolution within 3 wks | *Usually self-limiting with most experiencing resolution within 3 wks | ||
* | *Outpatient consult to ophtho for refractory cases, ulcers needing debridement, and multiple recurrences | ||
==See Also== | ==See Also== | ||
| Line 62: | Line 71: | ||
*Wang, J et al. Herpes Simplex Keratitis. Dec 7 2015. http://emedicine.medscape.com/article/1194268-overview#showall | *Wang, J et al. Herpes Simplex Keratitis. Dec 7 2015. http://emedicine.medscape.com/article/1194268-overview#showall | ||
[[Category: | [[Category:Ophthalmology]] | ||
[[Category:ID]] | |||
Latest revision as of 16:47, 12 March 2021
Background
- Most common cause of corneal blindness in US
- Avoid topical steroids to prevent necrotizing stromal keratitis
Conjunctivitis Types
Clinical Features
- Blurred vision
- Eye pain, photophobia
- More pain than with typical conjunctivitis
- Tearing
- Perilimbic injection
- Normal pupil size and intraocular pressure
- Dendritic ulcers with fluorescein
- May also see "geographic ulcers" - amoeba-like ulceration with dendrites at the edges[1]
- Severe cases may cause uveitis, iritis
Slit lamp/Fluorescein
- Epithelial disease
- Infectious epithelial keratitis
- Corneal vesicles rarely seen; dendritic ulcers form from coalesced corneal vesicles
- Enlarge into geographic ulcers, with scalloped borders
- Neurotrophic keratopathy
- Ulcers more oval, with smooth borders as opposed to geographic ulcers
- Irregular corneal surface from immune response
- Decreased corneal sensitivity due to scarring, necrosis
- Infectious epithelial keratitis
- Stromal keratitis - develops secondarily to in 25% of patients with epithelial disease
- Necrotizing stromal keratitis - leads to thinning and perforation
- Immune stromal keratitis - recurrent ocular HSV
- Endotheliitis (disease extending from epithelium to stroma to endothelium)
- Keratic precipitates
- Accompanying iritis
Differential Diagnosis
- Iritis
- Conjunctivitis
- Glaucoma
- UV keratitis
- Herpes zoster
- Contact lens complication
- Fungal keratitis
- Bacterial keratitis
- Interstitial keratitis
Herpes Simplex Virus-1
- Eczema herpeticum
- Herpes gingivostomatitis
- Herpes keratitis
- Herpes labialis (cold sore)
- Herpes simplex encephalitis
- Herpetic whitlow
Evaluation
Clinical diagnosis with staining and slit lamp exam
Management
- Topical options
- Acyclovir 3% ophthalmic ointment 5x daily
- Continued for three days after clearing of corneal lesions
- If unavailable, Ganciclovir ophthalmic gel 0.15% 5x daily
- Cycloplegic for symptoms - Cyclopentolate 1% x1 drop 3x daily, lasts for a day
- Acyclovir 3% ophthalmic ointment 5x daily
- Oral acyclovir (400mg 5x daily) or valacyclovir (500mg 3x daily) may be used alone or in combo with topical
- Treatment can be stopped one week after healing of the lesions
- Avoid topical steroids unless in consult with ophtho (steroids can be started when infectious treatment adequately underway)
Disposition
- Usually self-limiting with most experiencing resolution within 3 wks
- Outpatient consult to ophtho for refractory cases, ulcers needing debridement, and multiple recurrences
See Also
External Links
References
- ↑ Go S. Eye Emergencies. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed March 12, 2021. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158§ionid=162273694
- Wang, J et al. Herpes Simplex Keratitis. Dec 7 2015. http://emedicine.medscape.com/article/1194268-overview#showall