Download Herpes Simplex Virus Blepharoconjunctivitis

Herpes Simplex Virus
Blepharoconjunctivitis
Deborah Gill, MD; Todd P. Margolis, MD, PhD—Guest Authors
Rosalyn Stewart, MD, MS, FAAP, FACP
Leonard Feldman, MD—Column Editors
Herpes simplex virus (HSV) blepharoconjunctivitis is characterized by a
vesicular rash, tender preauricular adenopathy, and follicular conjunctivitis. It is
important to realize that the classic vesicular rash is frequently crusted over by
the time the patient is evaluated. The clinical findings may be much more subtle than those seen in Figure 1.
Figure 1.
HSV corneal infection most commonly presents as a dendriform epithelial
keratitis. Fluoresceine dye reveals the extent of the corneal surface affected
(Figure 2) whereas Rose Bengal (or lissamine green) identifies actively infected
epithelial cells at the leading edge of the infection. Sensation is usually markedly reduced in the affected portion of the cornea.
Figure 2.
HSV infection of the corneal stroma (stromal keratitis) is the most common
cause of infectious corneal blindness in the United States (Figure 3). Because
this disease can present in a number of different patterns and without a prior
history of HSV ocular disease, clinicians must have a high index of suspicion
that any form of corneal inflammation or scarring may be due to HSV.
Figure 3.
Patients with a history of atopy appear to have a greater risk for
Figure 4.
Figure 5.
recurrent and severe herpes simplex virus (HSV) ocular disease, and
this severity may manifest in different forms (Figures 4 and 5).
Furthermore, these patients often require more aggressive antiviral
therapy than do patients without atopic disease.
Antiviral agents are used to treat HSV lid disease, conjunctivitis,
and epithelial keratitis. Systemic medications, such as acyclovir (400 mg
by mouth, 5 times/day), are as effective as topical agents and are generally better tolerated. Stromal keratitis and iritis also require the use of
topical corticosteroids, which should never be used without antiviral coverage.
Because HSV keratitis can lead to blindness, all patients with any manifestation HSV infection in or around the eye should
be promptly referred to an ophthalmologist.
Dr Gill is a clinical and research fellow with the Proctor Foundation and Department of Ophthalmology. Dr Margolis is Professor of Ophthalmology, University
of California, and Director of the F. I. Proctor Foundation, San Francisco, California.
Dr Stewart is Assistant Professor, Department of Medicine, Division of General Internal Medicine, Johns Hopkins University, Baltimore, Maryland.
Dr Feldman is Instructor of Medicine, Department of Medicine, Division of General Internal Medicine-Hospitalist Service; Assistant Program Director, Osler
Medical Residency; Director, Comprehensive General Medicine Consult Service, Johns Hopkins Hospital, Johns Hopkins University, Baltimore, Maryland.
Johns Hopkins Advanced Studies in Medicine
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