In immune deficient patients or with the use of corticosteroids the ulcer may become large and in these cases it is called geographic ulcer. Disciform keratitis (Endothelial keratitis)
Endothelial keratitis manifests a central endothelitis in a disc-shaped manner. Longstanding corneal edema leads to permanent scarring and is the major cause of decreased vision associated with HSV. Localized endothelitis (localized inflammation of corneal endothelial layer) is the cause of disciform keratitis. Other forms
Metaherpetic ulcer : is not due to live virus, results from inability of the corneal surface to heal. Necrotizing keratitis
Keratouveitis : is usually granulomatous uveitis with large keratic precipitates on the corneal endothelium. Cause
HSV is a double-stranded DNA virus that has icosahedral capsid. HSV-1 infections are found more commonly in the oral area and HSV-2 in the genital area. Ocular herpes simplex is usually caused by HSV-1. Diagnosis
A specific clinical diagnosis of HSV as the cause of dendritic keratitis can usually be made by ophthalmologists and optometrists based on the presence of characteristic clinical features. Diagnostic testing is seldom needed because of its classic clinical features and is not useful in stromal keratitis as there is usually no live virus. Laboratory tests are indicated in complicated cases when the clinical diagnosis is uncertain and in all cases of suspected neonatal herpes infection:
Corneal smears or impression cytology specimens can be analyzed by culture, antigen detection, or fluorescent antibody testing. Tzanck smear, i.e.Papanicolaou staining of corneal smears, show multinucleated giant cells and intranuclear inclusion bodies, however, the test is low in sensitivity and specificity.
The effect of interferon with an antiviral agent or an antiviral agent with debridement needs further assessment. Stromal keratitis
Herpetic stromal keratitis is treated initially with prednisolone drops every 2 hours
accompanied by a prophylactic antiviral drug: either topical antiviral or an oral agent such as acyclovir or valacyclovir. The prednisolone drops are tapered every 1–2 weeks depending on the degree of clinical improvement. Topical antiviral medications are not absorbed by the cornea through an intact epithelium, but orally administered acyclovir penetrates an intact cornea and anterior chamber. In this context, oral acyclovir might benefit the deep corneal inflammation of disciform keratitis. Metaherpetic ulcer
Treatment includes artificial tears and eye lubricants, stopping toxic medications, performing punctal occlusion, bandage contact lens and amniotic membrane transplant. These measures intend to improve corneal epithelial healing. Antiviral medication may reduce the risk of HSV keratitis recurring in people having a graft due to HSV infection and may improve the chances of graft survival. References


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