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Herpetic eye disease (HSV and herpes zoster ophthalmicus)
HSV causes a dendritic ulcer of the corneal epithelium and recurrent stromal keratitis that leaves scars; herpes zoster in the first division of the trigeminal nerve affects the eye mainly when the nose is involved, and both are treated with antivirals — a steroid is forbidden in active epithelial disease.
Why it matters in the exam
Epithelial HSV presents as a red watery eye with photophobia and a "branching" ulcer that stains with fluorescein and has swellings at the ends of its branches (terminal bulbs), with reduced corneal sensation. Treatment is ganciclovir 0.15% gel, trifluridine or oral acyclovir. Stromal keratitis is an immune reaction: stromal haze and oedema, treated with a topical steroid under antiviral cover. The HEDS study showed that oral acyclovir 400 mg twice daily for 12 months reduces recurrences by about half, so it is given as prevention in recurrent stromal disease.
Herpes zoster ophthalmicus — a vesicular rash in the upper division of the trigeminal nerve. The Hutchinson sign — vesicles on the tip of the nose (nasociliary nerve) — predicts ocular involvement. Oral treatment within 72 hours of the rash: valacyclovir 1 g three times daily or acyclovir 800 mg five times daily for 7 days. Complications: "pseudodendritic" keratitis without end bulbs, uveitis with raised pressure, neurotrophic keratopathy, cranial nerve palsies and postherpetic neuralgia. Prevention: the Shingrix vaccine for people aged 50 and over.
Neurotrophic keratopathy is the end of the road after many recurrences: the cornea loses sensation, the epithelium does not close and an oval ulcer with raised edges forms. Further antiviral does not help here — treatment is preservative-free lubrication, a bandage lens, lid closure or cenegermin. A family physician who gives steroid drops for a red eye without a slit-lamp examination may turn a dendritic ulcer into a large "geographic" ulcer.
Key points
- Epithelial HSV: dendritic ulcer, reduced sensation; antiviral.
- Stromal HSV: steroid with antiviral cover.
- HEDS: acyclovir prevents about half of recurrences.
- Zoster: Hutchinson sign and valacyclovir within 72 hours.
- Many recurrences → neurotrophic keratopathy.
Summary table
| Form | Finding | Treatment |
|---|---|---|
| Epithelial HSV | Dendritic ulcer with terminal bulbs | Ganciclovir gel, trifluridine or oral acyclovir; no steroid |
| Stromal HSV | Stromal haze and oedema | Topical steroid with antiviral cover |
| Preventing recurrences | More than one stromal episode | Acyclovir 400 mg twice daily |
| Herpes zoster ophthalmicus | Rash in the upper division, Hutchinson sign | Valacyclovir 1 g three times daily, 7 days |
| Neurotrophic keratopathy | Oval ulcer, reduced sensation | Lubrication, bandage lens, cenegermin |
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Sources
- Herpetic Eye Disease Study (HEDS) Group: Acyclovir for the prevention of recurrent herpes simplex virus eye disease, 1998 — Results
- AAO Basic and Clinical Science Course, Section 8: External Disease and Cornea, 2024-2025 — Herpes simplex and varicella-zoster eye disease
- Kanski's Clinical Ophthalmology, 9th edition (2020) — Cornea
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.