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Cornea editor's corner of the world Herpes simplex keratitis (HSV) is one of the most challenging entities that faces ophthalmologists. A geographic ulcer with fluorescein staining of the base of the ulcer and rose bengal staining of the peripheral terminal end bulbs Source: Vincent P. Herpes ocular infection is one of the leading causes of infectious corneal blindness in the United States and Europe, according to Vincent P.
With these older medications, practitioners were seeing corneal epithelial toxicity in the form of punctate keratitis and even more serious effects.
With the availability of ganciclovir gel, treatment preferences for HSV keratitis are now somewhat in flux. The fact that toxicity is less of a factor makes the decision to use topical therapy alone easier. The cornea is the transparent anterior portion of the outer layer of the eye, corresponding to a watch crystal.
The cornea’s front and rear surface curvatures are critical to its role as a lens focusing light into the eye. The tear film and epithelial layer are the principal barriers of the cornea to external infectious agents.
Fuchs’ endothelial dystrophy (FED) is a disorder of the corneal endothelium characterized by premature death of endothelial cells and development of characteristic nodules on Descemet’s layer, referred to as guttae.
Patients with early epithelial edema may benefit from treatment with salt water eye drops and ointment. Herpes simplex virus is a member of the family of viruses that also includes cytomegalovirus, varicella-zoster virus and Epstein-Barr virus. For more information about Corneal Disease, or to schedule an appointment, please complete our online form or call (973) 328-6622. A ulcerative keratitis or corneal ulcer is a condition, in which there is the infection of cornea, on iris open sore, at eye colored part. Enter your email address to subscribe to this blog and receive notifications of new posts by email. Topical antivirals have had significant toxicity, and the more recent trend has been to use oral antiviral agents to manage HSV keratitis. Hovanesian finds that because ganciclovir is not toxic to the epithelium, successful healing of HSV keratitis is evident to both the patient and the physician at an earlier stage.
Hovanesian pointed out that the new ganciclovir gel, while a real step up for HSV keratitis, is not likely to be a moneymaker for the pharmaceutical company like an antibiotic would be.

Nerve endings terminate primarily within the epithelium, making any disruption of the epithelial layer particularly painful. The cornea provides two-thirds of the focusing power of the eye, compared to one-third for the lens. Disruption of these defenses makes the cornea more vulnerable to infection, which is why contact lens wearers are more prone to serious corneal infections. Loss of endothelial cells occurs normally with aging, but in FED the cell dropout is much more pronounced.
A bandage soft contact lens can relieve pain caused by epithelial edema and bullae formation. All ocular tissues are vulnerable to infection but keratitis, or corneal infection, is most common. In children who are insufficient of Vitamin A, will be suffering with corneal ulcer and in some conditions they may suffer from blindness for life period. The symptoms also may appear anterior uvetis, redness of the eye, aqueous flare and small pupil. The cornea consists of five layers: epithelium, Bowman’s layer, stroma, Descemet’s membrane and endothelium.
Corneal nerves play a role in maintaining a healthy ocular surface, and diseases that damage corneal nerves such as herpes simplex keratitis and diabetes may create long term difficulty.
A disturbance of normal corneal curvature creates blurred vision that may not be able to be effectively corrected with eyeglasses or contact lenses. Lens-induced minor trauma to the cornea provides a route for bacteria to invade the tissue. Corneas with FED may decompensate or develop severe edema after intraocular surgery such as cataract removal. After primary infection at a peripheral site, herpes simplex virus resides in sensory nerve ganglia (most commonly the trigeminal), autonomic ganglia or the brain stem.
We can see this corneal ulcer more in developing countries owing to nerve exposure, painful and some times tearing also. Pathology can involve these layers individually, as in Fuchs’ dystrophy, a disorder of the endothelial layer, or in combination, as is the effect of a corneal ulcer. Kerataconus is a corneal warping disorder for which glasses and soft contact lenses often cannot effectively correct vision.
A poor tear film in dry eye patients can induce epithelial breakdown that may be complicated by infection.

For this reason, it is important for patients to recognize the risk of proceeding with intraocular surgery.
I have asked two corneal experts to comment on their approach to HSV keratitis and how, if at all, this new medication has changed their management.
However, in doing this he cautions against pushing too deeply with the swab since this could push the viral antigen deeper into the stroma.
The principal functions of the cornea in vision are to permit transmission of light into the eye and to focus it onto the retina. This cell layer pumps fluid out of the cornea and into the eye, which maintains corneal dehydration.
Kerataglobus, Terrien’s marginal degeneration, Salzmann’s nodular degeneration and pterygia also cause blurred vision by affecting corneal curvature. Patients with conditions that result in poor healing of the corneal epithelial surface will frequently have their condition complicated by infection.
There is a reduction in vision associated with moderate stromal edema that is more severe when epithelial edema is noted as well.
If severe edema develops, the only treatment options become a full thickness corneal transplant or Descemet’s stripping endothelial keratoplasty.
Under certain conditions it then reactivates, travels down the nerve to the peripheral end organ and causes recurrent disease.
Recurrent infection can lead to more serious stromal keratitis that may be complicated by corneal ulceration, deep scarring and vascularization. Maintenance of corneal clarity is essential to both functions, and diseases associated with a loss of corneal clarity invariably reduce vision quality. Disorders affecting the endothelium, such as Fuchs’ dystrophy, result in corneal swelling and clouding.
Healing the epithelial surface is critically important in managing patients with corneal exposure, corneal erosions, chemical burns and neurotrophic disease. Patients with early epithelial edema often note fluctuation of their vision quality, with blurring more pronounced in the morning.

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