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Herpes Simplex Endotheliitis
ABSTRACT
Herpes simplex keratitis is the leading cause of infectious vision loss in the United States. Proper
classification and treatment are essential to optometric practice. Herpes simplex endotheliitis is an
immune-mediated keratitis that requires anti-inflammatory and anti-viral treatment.
I.
Case History
- 63 year old white male Veteran with insufficient housing
- Complains of OS redness, irritation, soreness, photophobia onset 1 day
- Ocular history: recurrent herpes simplex keratitis OS first episode in 1970's, most recent
episode in 2003
- Medical history: Paranoid state, personality disorder
- Medications: Fish oil, Multi-vitamin
- Patient refuses other medications and medical care
II. Pertinent Findings
- VA OS: PH 20/50
- Conjunctiva: moderate injection OS
- Cornea: Circular area of stromal haze extending from superior nasal quadrant into the
visual axis; temporal stromal scarring with neovascularization; punctuate staining
superior temporal and nasal OS
- Anterior Chamber: Clear (-)cells (-)flare OS
- GAT: OD: 18mmHg OS: 19mmHg
- Posterior pole: unremarkable
III. Differential diagnosis
- Recurrent Herpes Simplex Epithelial Keratitis
- Herpes Zoster Epithelial Keratitis
- Bacterial keratoconjunctivitis
- Allergic keratoconjunctivitis
- Viral keratoconjunctivitis
IV. Diagnosis and Discussion
- Diagnosed with HSV epithelial keratitis OS- started on Viroptic 9x/day OS
- Patient RTC 5 days later and had developed stromal edema superior nasal extending
into visual axis w/ numerous keratic precipitates, cells, and flare. Epithelium was intact.
IOP=14 mmHg and posterior pole unremarkable.
- Diagnosis was changed to HSV Endotheliitis OS
o Disciform area of stromal and epithelial edema
o Anterior chamber reaction
o Mutton-fat keratic precipitates
o Intact corneal epithelium
- Disciform endotheliitis= Immune herpes
o Pathophysiology of immune response in endotheliitis
-
Typically slow healing with long/ slow steroid taper
o Patient non-compliant: D/C from all meds in 2 weeks
V. Treatment, Management
- Pred forte QID OS, Cyclopentolate QID OS, Viroptic QID OS for 1 week
- Px non-compliant at follow up; D/C Cyclopentolate and Viroptic, px told to continue
Pred BID OS for 1 week.
- Px had D/C all meds at follow-up with resolution of symptoms
- Typically keep antiviral cover until steroid reduced to QD or QOD dosing
- HEDS study
- Role of oral Acyclovir
- Long-term effects
VI. Bibliography
- Amano, S., et. al.; Herpes Simplex Virus in the Trabeculum of an Eye with Corneal
Endotheliitis. Am J Ophthalmol 1999; 127:721-722.
- Barron BA, et.al; Herpetic Eye Disease Study: A controlled trial of oral acyclovir for
herpes simplex stromal keratitis. Ophthalmol 101:1871-1882, 1994.
- Ehlers, J., Shah C.; The Wills Eye Manual-5th edition. Lippincott Williams & Wilkins. Pg
70-74
- Hayashi, K., et. al.; Who (what) pays toll for the development of herpetic stromal
keratitis. Semin Ophthalmol. 2008 Jul-Aug;23(4):229-34.
- Herpetic Eye Disease Study Group:A controlled trial of oral acyclovir for iridocyclitis
caused by herpes simplex virus. Arch Ophthalmol 114:1065-1072, 1996.
- Hirose, N.; Corneal endothelial changes associated with herpetic stromal keratitis. Jpn J
Ophthalmol. 1988;32(1):14-20
- Holbach, L., et.al.; Infection of the corneal endothelium in herpes simplex keratitis. Am J
Ophthalmol 1998; 126:592-594
- Kanski, J. Clinical Ophthalmology- 3rd ed. Butterworth-Heinemann. Pg 108-111.
- Olson, R.; The Four Key Stages of Herpes Simplex Virus. Vol. No: 12:10 Issue10/01/2005
- Pepose, J.; Herpes Simplex Keratitis: Role of Viral Infection Virus Immune Response.
Survey of Ophthalmol 1991; 35 (5).
- Philipp, W., et. al.; Expression of vascular endothelial growth factor and its receptors in
inflamed and vascularized human cornea. Invest Ophthalmol Vis Sci. 2000;41:25142522.
- Saini, J., et.al.; Clinical pattern of recurrent herpes simplex keratitis. Indian J Ophthalmol
1999;47:11-14.
- Starr, P.A.; Changes in the permeability of the corneal endothelium in herpes simplex
stromal keratitis. Proc roy soc med. Vol 61 June 1968.
- Sundmacher, R.; Herpes simplex virus isolations from the aqueous of patients suffering
from focal iriris, endotheliitis, and prolonged disciform keratitis with glaucoma. Klin
Monatsbl Augenheilkd. 1997 Oct; 175(4):488-501.
- Sugioka, K., et.al.; Susceptibility of human corneal endothelial cells to HSV-1 infection.
Curr Eye Res. 2007 Mar;32(3):299.
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Vannas, A., et.al.; Corneal Endothelium in Herpetic Keratouveitis. Arch Ophthalmol
1983: 101:913-915.
Vannas, A.; Herpetic endothelial keratitis. A case report. Acta Ophthalmol 1981
Apr;59(2):296-301.
Wilhelmus, K.R., et. al.; Risk factors for herpes simplex virus epithelial keratitis recurring
during treatment of stromal keratitis or iridocyclitis. Brit J Ophthalmol 1996; 80:969972.
Wilhelmus, K.R., et.al.; Corneal thickness changes during herpes simplex virus disciform
keratitis. Cornea. 2004 Mar;23(2):154-7.
VII. Conclusion
- Understand different classifications of HSV keratitis
- Pathophysiology of HSV Endotheliitis
- Treatment options
- Monitor for permanent endothelial damage, scarring, glaucoma, recurrence