Herpes and the eye

Herpes and the eye_top banner

Almost 90% of us have evidence of exposure to the herpes virus and are immune. Most people will not even have realised that they have been infected at some time.

Around 1% of us are not adequately immune to suppress the virus, which lies dormant, and becomes active from time to time.

There are two types of Herpes Virus:

Type 1 – Affecting face, lips and eyes
Type 2 – Genitals – will not be part of this discussion

A first-time infection – usually affecting young children – may lead to:

  • Vesicles, which are tiny blisters on the skin around the eye – the vesicles crust after several days and the skin heals
  • Conjunctivitis with watery discharge
  • Sometimes dendritic ulcers may appear on the front window of the eye (cornea)

For most people the virus makes itself felt as recurrent cold sores or eye problems. Frequently patients have no recollection of the primary infection, or it was so mild that it was not noticeable. The first symptoms may just be related to a dendritic ulcer or keratitis.

A child with primary herpes infection around the right eye.

Recurrent herpes infection.

Recurrent episodes occur, particularly when you are run-down or fighting another infection.

Dendritic ulcers occur on the front surface of the eye, the cornea. They have a characteristic branching appearance, hence the name describing their dendritic pattern. The eye is red and watery and slightly light intolerant (photophobic). Vision can be reduced and misty if the ulcer is over the pupil.

Keratitis is a term describing inflammation of the cornea. This can reduce the vision considerably, leading to more light intolerance and more discomfort.

Herpes may cause a chronic uveitis with characteristic iris changes.

Treatment

An ophthalmologist should manage this.

  • Aciclovir (anti-viral) ointment, initially five times daily, and subsequently tapered off is standard
  • Addition of a mild steroid drop may be required to reduce inflammation and prevent scarring
  • When there is recurrent keratitis steroid drops will be required. There is a fine line balancing the steroid drops and aciclovir ointment, since steroids may suppress the immune effects against the virus and let it get out of control
  • In some patients who have had recurrent episodes of the inflammation, long-term oral (by mouth) low doses of antiviral agents such as acyclovir or valaciclovir may be required to suppress viral activity

Courtesy Chris Barry

These images show both the denrtitic ulcers and the keratitis with scarring and subsequent blurring of vision. Note the branching pattern with terminal bulbs.