18/07/2018
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Note: The estimated completion time includes time spent reading this article and studying the figures.A 45-year-old female was referred for increasing blurred vision and photophobia in her right eye over the preceding week, with reduced foreign-body sensation. She had previously been referred to an ophthalmologist with similar symptoms.
RVA: 6/7.5
LVA: 6/5
The patient reveals a history of cold sores, including a recent flare-up. Approximately 12 months ago, she had seen another ophthalmologist for the same symptoms and the patient notes confirmed she had been treated with Maxidex and Zovirax.
Given her history and presence of small epithelial defects (but not dendrites), it is highly likely this patient has herpes simplex virus (HSV) keratouveitis.
Oral famciclovir was discussed with the patient as an alternative anti-viral option. Compared to topical Zovirax, oral famciclovir offers quicker resolution of symptoms, less corneal toxicity and some added benefit if uveitis is present. However, the cost is often prohibitive for patients because it is not listed on the PBS for HSV.
2 weeks after presentation
4 weeks after presentation
The patient was asked to return for a review in 1–2 weeks and again 2 weeks after stopping treatment (or ASAP if symptoms are worsening).
Topical corticosteroids should be avoided in the initial management of HSV epithelial keratitis.
If AC inflammation is severe, steroids may need to be administered more frequently.
Prophylaxis is considered in patients with:
Herpes viruses, including HSV1, HSV2 and VSV, can all affect the eye. The possible diagnosis of such conditions should always be kept in the back of the mind in any patient presenting with corneal inflammatory changes (oedema, infiltrates, epithelial defect) and/or uveitis. Any patient with suspected corneal herpetic disease must have a dilated exam to look for intraocular involvement.
Dr Nima Pakrou is an experienced ophthalmologist with expertise across a range of eye conditions. His subspecialty areas include medical retinal diseases, cataracts, intraocular inflammation and oculoplastics. He practises at Vision Eye Institute Footscray.
This article is for educational and informational purposes only and may not be directly applicable to your individual patients.
Date last reviewed: 2023-08-14 | Date for next review: 2025-08-14