A 48-Year-Old Man With Tearing and Photophobia

Alissa M. Coyne, OD; Case Series Editor: Jean Marie Pagani, OD

Disclosures

July 25, 2013

Discussion

Herpes simplex virus is the most common virus found in humans, and approximately 90% of the United States population is affected.[2,4,5] Less than 20% of infected individuals manifest cutaneous or ocular disease. Although only a minute percentage of people with herpes simplex virus develop ocular manifestations, this still means that about 400,000 Americans have had some type of ocular herpes simplex virus infection. Unilateral infection is present in more than 90% of cases; in bilateral incidences, systemic immune issues should be considered if atopic disease is not present.[6] Approximately 25% of patients with a history of herpes simplex keratitis will experience a recurrence within 2-5 years of the first episode.[6,7]

After the primary herpes simplex virus infection, the virus spreads from the affected epithelial cells to nearby sensory endings. The virus is transferred to the trigeminal ganglion and remains in a dormant state.[8] Any branch of the trigeminal nerve can be affected during the primary infection, and interneuronal spread of the infection within the ganglion puts all infected individuals at risk for ocular manifestations of the virus. Recurrent ocular herpes simplex virus infection is a reactivation of the virus in the trigeminal ganglion, which then travels down the nerve axon to produce infection in ocular tissues.[8,9] Studies have shown that the latent virus can survive in the cornea and act as a source of recurrent infection.[9,10,11] This may also be the cause of herpetic eye disease in transplanted corneas.

The visual prognosis of individuals with herpetic dendrites is dependent on the extent of the infection and residual scarring. The patient in this case has a positive prognosis because he had very minimal scarring from his episode. At his final examination, he was correctable to 20/20 in both eyes with no visual complaints.

Conclusion

Herpes simplex infectious epithelial keratitis is a self-limited infection. However, prompt and aggressive management is recommended to limit the amount of scarring as a result of the infection. The recent addition of ganciclovir to the US market has added another viable option to the eye care professional's treatment arsenal. The future lies in vaccination studies targeting herpes simplex virus-2 with cross-reactivity in preventing herpes simplex virus ocular infections.[12]

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