Herpes simplex keratitis


  • Most common cause of corneal blindness in US
  • Avoid topical steroids to prevent necrotizing stromal keratitis

Conjunctivitis Types

Clinical Features

Herpes keratitis
  • Blurred vision
  • Eye pain, photophobia
    • More pain than with typical conjunctivitis
  • Tearing
  • Perilimbic injection
  • Normal pupil size and intraocular pressure
  • Dendritic ulcers with fluorescein
    • May also see "geographic ulcers" - amoeba-like ulceration with dendrites at the edges[1]
  • Severe cases may cause uveitis, iritis

Slit lamp/Fluorescein

  • Epithelial disease
    • Infectious epithelial keratitis
      • Corneal vesicles rarely seen; dendritic ulcers form from coalesced corneal vesicles
      • Enlarge into geographic ulcers, with scalloped borders
    • Neurotrophic keratopathy
      • Ulcers more oval, with smooth borders as opposed to geographic ulcers
      • Irregular corneal surface from immune response
      • Decreased corneal sensitivity due to scarring, necrosis
  • Stromal keratitis - develops secondarily to in 25% of patients with epithelial disease
    • Necrotizing stromal keratitis - leads to thinning and perforation
    • Immune stromal keratitis - recurrent ocular HSV
  • Endotheliitis (disease extending from epithelium to stroma to endothelium)
    • Keratic precipitates
    • Accompanying iritis

Differential Diagnosis

Herpes Simplex Virus-1


Clinical diagnosis with staining and slit lamp exam


  • Topical options
    • Acyclovir 3% ophthalmic ointment 5x daily
      • Continued for three days after clearing of corneal lesions
    • If unavailable, Ganciclovir ophthalmic gel 0.15% 5x daily
    • Cycloplegic for symptoms - Cyclopentolate 1% x1 drop 3x daily, lasts for a day
  • Oral acyclovir (400mg 5x daily) or valacyclovir (500mg 3x daily) may be used alone or in combo with topical
    • Treatment can be stopped one week after healing of the lesions
  • Avoid topical steroids unless in consult with ophtho (steroids can be started when infectious treatment adequately underway)


  • Usually self-limiting with most experiencing resolution within 3 wks
  • Outpatient consult to ophtho for refractory cases, ulcers needing debridement, and multiple recurrences

See Also

External Links


  1. Go S. Eye Emergencies. In: Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma O. eds. Tintinalli's Emergency Medicine Manual, 8e. McGraw-Hill; Accessed March 12, 2021. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2158&sectionid=162273694