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Herpes Simplex Keratitis

(Herpes Simplex Keratoconjunctivitis)

By

Melvin I. Roat

, MD, FACS, Sidney Kimmel Medical College at Thomas Jefferson University

Medically Reviewed Aug 2022 | Modified Sep 2022
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Herpes simplex keratitis is corneal infection with herpes simplex virus. It may involve the iris. Symptoms and signs include foreign body sensation, lacrimation, photophobia, and conjunctival hyperemia. Recurrences are common and may lead to corneal hypoesthesia, ulceration, permanent scarring, opacification, thinning of the corneal stroma, and decreased vision. Diagnosis is based on the characteristic dendritic corneal ulcer and sometimes viral culture. Treatment is with topical or systemic antiviral drugs.

Herpes simplex keratitis usually affects the corneal surface but sometimes involves the corneal stroma (the deeper layers of the cornea) or the inner corneal surface (endothelium), anterior chamber, and iris. Stromal involvement is probably an immunologic response to the virus.

Herpes simplex keratitis is a major cause of blindness worldwide.

Symptoms and Signs of Herpes Simplex Keratitis

Primary infection

The initial (primary) infection is usually nonspecific self-limiting conjunctivitis, often in early childhood and usually without corneal involvement. If the cornea is involved, symptoms include foreign body sensation, lacrimation, photophobia, and conjunctival hyperemia. Sometimes vesicular blepharitis (blisters on the eyelid) follows, symptoms worsen, vision blurs, and blisters break down and ulcerate, then resolve without scarring in about a week.

Recurrent infection

Recurrent ocular herpes affects the cornea. Three main types of herpes simplex keratitis are

  • Epithelial keratitis (dendritic keratitis)

  • Disciform keratitis (localized endotheliitis)

  • Stromal keratitis

Reactivation of latent herpes simplex can be triggered by UV light exposure (eg, intense sunlight, corneal cross-linking [an ultraviolet light treatment that stiffens the cornea], or laser refractive procedures), fever, menstruation, significant systemic physical stress (eg, burns or multiple fractures), immunosuppression, or use of glucocorticoids (topical ophthalmic, periocular injection, intraocular injection, or systemic). Recurrences usually take the form of epithelial keratitis (also called dendritic keratitis), with tearing, foreign body sensation, and a characteristic branching (dendritic or serpentine) lesion of the corneal epithelium with bulb-like terminals that stain with fluorescein. Multiple recurrences may result in corneal hypoesthesia or anesthesia, ulceration, permanent scarring, opacification, thinning of the corneal stroma, and decreased vision.

Most patients with disciform keratitis, which involves the corneal endothelium primarily, have a history of epithelial keratitis. Disciform keratitis is a deeper, disc-shaped, localized area of secondary corneal stromal edema and haze accompanied by anterior uveitis. This form may cause ache, photophobia, and reversible vision loss.

Stromal keratitis is likely to cause necrosis of the stroma and severe ache, photophobia, foreign body sensation, ulceration, permanent scarring, opacification, neovascularization, thinning of the corneal stroma, and irreversible decreased vision.

Diagnosis of Herpes Simplex Keratitis

Treatment of Herpes Simplex Keratitis

  • Topical ganciclovir or trifluridine

  • Oral or IV acyclovir or valacyclovir

  • For stromal involvement or uveitis, topical corticosteroids in addition to antiviral drugs

Most patients are managed by an ophthalmologist. If stromal or uveal involvement occurs, treatment is more involved and referral to an ophthalmologist is mandatory.

Dendritic (epithelial) keratitis can be treated with topical therapy (eg, ganciclovir 0.15% gel applied every 3 hours while awake [5 times/day] or trifluridine 1% drops every 2 hours while awake [9 times/day]). Topical therapy is usually effective and is tapered off over 2 to 3 weeks.

Alternatively, oral therapy (eg, acyclovir 400 mg orally 3 to 5 times/day or valacyclovir 1000 mg orally twice/day) is also effective. Acyclovir 400 mg orally twice/day or valacyclovir 500 to 1000 mg orally once/day may be prescribed as suppressive therapy to prevent frequent recurrences as well as to preserve eyesight in patients whose vision has been threatened.

Immunocompromised patients may require IV antivirals (eg, acyclovir 5 mg/kg IV every 8 hours for 7 days).

Topical corticosteroids are contraindicated in epithelial keratitis, but they may be effective when used with an antiviral to manage later-stage stromal involvement (disciform or stromal keratitis) or uveitis Overview of Uveitis Uveitis is defined as inflammation of the uveal tract—the iris, ciliary body, and choroid. However, the retina and fluid within the anterior chamber and vitreous are often involved as well.... read more Overview of Uveitis . In such cases, patients may be given prednisolone acetate 1% instilled every 2 hours initially, lengthening the interval to every 4 to 8 hours as symptoms improve.

If the epithelium surrounding the dendrite is loose and edematous, debridement by gentle swabbing with a cotton-tipped applicator before beginning drug therapy may speed healing. Topical drugs to relieve photophobia include atropine 1% or scopolamine 0.25% 3 times a day.

Key Points

  • Herpes simplex keratitis typically is a recurrence of primary herpes simplex eye infection that was usually a nonspecific, self-limiting conjunctivitis.

  • Characteristic findings include a branching dendritic or serpentine corneal lesion (indicating dendritic keratitis), disc-shaped, localized corneal edema and haze plus anterior uveitis (indicating disciform keratitis), or stromal scarring (indicating stromal keratitis).

  • Diagnosis is confirmed by finding a dendritic ulcer, by viral culture, or by NAAT swab.

  • Treatment requires antivirals, usually topical ganciclovir or trifluridine or oral acyclovir or valacyclovir.

Drugs Mentioned In This Article

Drug Name Select Trade
AK-Fluor, Fluorescite, Fluorets , Fluor-I-Strip, Fluor-I-Strip A.T., Ful-Glo, Ophthalmicflur
Cytovene, Vitrasert, Zirgan
Viroptic
Sitavig, Zovirax, Zovirax Cream, Zovirax Ointment, Zovirax Powder, Zovirax Suspension
Valtrex
AK-Pred, AsmalPred, Econopred, Econopred Plus, Flo-Pred, Hydeltrasol, Inflamase Forte, Inflamase Mild, Millipred , Millipred DP, Millipred DP 12-Day, Millipred DP 6 Day, Ocu-Pred , Ocu-Pred A, Ocu-Pred Forte, Omnipred, Orapred, Orapred ODT, Pediapred, Pred Mild, Predalone, Pred-Forte, Prednoral, Pred-Phosphate , Prelone, Veripred-20
Atreza, Atropine Care , Atropisol , Isopto Atropine, Ocu-Tropine, Sal-Tropine
Isopto Hyoscine, Maldemar, Scopace, Transderm Scop
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