Findings
Herpes Simplex
Epithelial: dendritic (with terminal bulbs)
Endothelial: disciform endothelial keratitis
Uveitis: recurrent, granulomatous, anterior, unilateral, iris atrophy, with or without corneal involvement, elevated intraocular pressure
Herpes Zoster
Epithelial: multiple pseudodendritic lesions (no terminal bulbs), neurotrophic disturbance (corneal sensitivity/Cochet-Bonnet esthesiometry)
Diagnosis
Clinical diagnosis (no swab/blood test)
Differential diagnosis
Herpes simplex, herpes zoster, recurrent erosions, bacterial/viral keratitis
Treatment
Skin involvement
- Valacyclovir 1g tablet (Valtrex) 3x/day for 7 days, then reduce (prophylactic dose 250mg 2x/day for at least 3 months)
- Additionally for herpes zoster
- Non-superinfected skin lesions (crusting): zinc solution (Aqua Dalibouri solution applied 1x/day with compresses for 15 minutes)
- Superinfected skin lesions (yellowish coating): topical betamethasone and antibiotic (Fucicort cream 2x/day)
Conjunctivitis
- Topical valacyclovir eye ointment (AciVision) or ganciclovir eye gel (Virgan) 5x/day until 3 days after healing
- Intensive lubrication with hyaluronic acid eye drops (Lacrycon, Optava) hourly
Keratitis
- Topical valacyclovir eye ointment (AciVision) or ganciclovir eye gel (Virgan) 5x/day until 3 days after healing
- Intensive lubrication with hyaluronic acid eye drops (Lacrycon, Optava) hourly
- Antibiotic prophylaxis (Floxal SDU 3x/day)
- Additionally for stromal involvement
- Topical steroids (Dexa Free eye drops 4x/day)
- Valacyclovir 1g tablet (Valtrex) 3x/day for 7 days
- Additionally if corneal graft rejection is suspected
- Prednisone 0.5-1mg/kg body weight, then taper
- Additionally for elevated intraocular pressure
- Topical beta-blocker/carbonic anhydrase inhibitor (Cosopt eye drops 2x/day)
Uveitis
- Valacyclovir 1g tablet (Valtrex) 3x/day for 7 days, then reduce (prophylactic dose 250mg 2-3x/day for at least 3 months)
- Topical steroids (Pred Forte eye drops 6x/day), then taper quickly
- Topical mydriasis/cycloplegia (scopolamine eye drops 0.25% 2x/day
- Additionally for elevated intraocular pressure
- Topical beta-blocker/carbonic anhydrase inhibitor (Cosopt eye drops 2x/day)
Retinal involvement, see the retina section
Special considerations
Children: treatment always in consultation with a pediatrician
Chickenpox: consider symptomatic treatment of itching due to risk of scarring (Fenistil, Tavegyl)
Immunosuppressed patients: increased risk of retinal involvement
Trigeminal neuralgia: sudden shooting pain and paresthesia in the dermatome of the trigeminal nerve. Treatment with pregabalin/amitriptyline if needed
Sources: Eyewiki.org, Wills Eye Manual
