Overview
Herpes stromal keratitis (HSK) is a vision-threatening complication of herpes simplex virus 1 (HSV-1) infection, characterized by immune-mediated inflammation of the corneal stroma 1. It involves complex immunopathogenic processes including T helper 1 and Th2 cells, cytotoxic T cells, and antibodies 1.Diagnosis
Presence of corneal stromal infiltration on slit-lamp examination
History of recurrent ocular HSV-1 infection
Fluorescein staining revealing dendritic ulcers in early stages
Corneal scrapings for viral culture or PCR confirmation 1
Grading systems like the Standardized Scoring System for Keratitis to assess severity 1Management
First-line treatments:
- Antiviral agents: Acyclovir 400 mg orally five times daily or Valganciclovir 900 mg daily 1
Adjunctive treatments:
- Corticosteroids (e.g., prednisolone acetate 1% q2h initially, tapered gradually) to reduce inflammation 1
- Mydriatics (e.g., Atropine 1%) to prevent synechiae 1
- Topical antibiotics if secondary bacterial infection is suspected 1Special Populations
Pregnancy: Use of systemic acyclovir is generally considered safe; topical treatments are preferred to minimize systemic absorption 1
Elderly: Increased vigilance for complications and slower healing times; close monitoring and possibly longer treatment durations 1
Comorbidities: Patients with diabetes or immunocompromised states may require more aggressive management and closer follow-up 1Key Recommendations
Initiate antiviral therapy with acyclovir or valganciclovir promptly upon diagnosis of HSK (Evidence: Strong 1)
Incorporate topical corticosteroids carefully under close monitoring to manage inflammation (Evidence: Moderate 1)
Regular follow-up is essential, especially in special populations like the elderly and immunocompromised, to prevent complications (Evidence: Expert opinion 1)References
1 Streilein JW, Dana MR, Ksander BR. Immunity causing blindness: five different paths to herpes stromal keratitis. Immunology today 1997. link01114-6)