Corneal Herpetic Infections

Herpetic infections of the eye can produce conjunctivitis, corneal inflammation (keratitis), and uveitis (inflamed iris, ciliary body, and choroid). The herpes simplex virus (HSV) is the most common cause of corneal opacification in temperate-zone countries. The human is the only natural host for this DNA virus. Approximately 90% of the population has systemic antibodies to HSV. The incubation period of HSV infection is 2 to 12 days. HSV type 1 (HSV-1) is the most common cause of ocular infection, but transmission of HSV-2 also can occur. Although classically HSV-1 is the oral type and HSV-2 is the genital type, current epidemiologic studies indicate that either type may be the source of corneal infection, and therefore cultures and viral titers are often sent for both types.

Primary Herpes Simplex Infection

Primary ocular infection in a nonimmune subject usually presents as conjunctivitis with a clear watery discharge, skin vesicles on the lids, and preauricular nodes. Associated vesicles and ulcers on the oral mucosa and skin are common. Corneal involvement also may occur with single or multiple dendrites. If dendrites are present, the patient should be referred for treatment. Particular attention should be given to inspecting the nose for possible lesions. A lesion at the tip of the nose indicates involvement of the cornea through the nasociliary branch of cranial nerve V. Treatment generally involves trifluridine 1% (Viroptic) drops five times daily for 10 to 14 days. If other regions are involved, oral acyclovir is added to trifluridine, as in eyelid or corneal involvement. These patients should be managed by an ophthalmologist.

Recurrent Corneal Herpetic Infections

At the time of the primary herpetic infection, the virus gains access to the CNS, where it resides in a latent state in the trigeminal and other ganglia. Recurrent attacks occur when the latent state is reversed. The virus travels via the sensory nerves to target tissues, one of which is the eye. Recurrent corneal involvement also includes the development of single or multiple dendritic ulcers. After a brief period, the plaque of epithelial cells desquamates to form a linear branching ulcer (dendrite). When a corneal dendrite is detected by corneal staining with fluorescein, the patient should be referred.

Preseptal Cellulitis

Preseptal cellulitis involves the eyelid and periorbital soft tissues and is characterized by acute eyelid erythema and edema. The infection usually occurs in the setting of an upper respiratory tract infection, external ocular infection, or trauma to the eyelids. Patients may have a mild fever and tend to complain of epiphora, conjunctivitis, and localized tenderness. However, the signs of orbital cellulitis are generally absent, unless a preseptal cellulitis evolves into an orbital cellulitis. Treatment is initiated empirically in most cases with cefuroxime, ceftriaxone, or nafcillin.

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