Board Review Questions of the Week – Eye Infections

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This week’s case-based question:

A 65-year-old woman presents complaining of foreign body sensation and decreased vision in her right eye over the past week. Fluorescein stain examination is seen in Figures 1 and 2.

Figure 1.

Figure 2.

Which of the following statements is correct?

Answer Options

If the patient has pustules on the surrounding skin, then she should be treated with acyclovir ophthalmic ointment and prednisolone 1%.
If this is a recurring problem and the patient has a history of herpes simplex infections, then she should be treated with cold compresses and topical prednisolone 1%.
If this is the first occurrence and the patient has a history of chickenpox infection as a child, then she should be treated with topical and oral acyclovir.
Treat her with a topical antiviral (eg, ganciclovir 0.15%, trifluridine 1%, vidarabine 3%), oral acyclovir, and homatropine 1%.

And the answer is …

Correct Answer:

Treat her with a topical antiviral (eg, ganciclovir 0.15%, trifluridine 1%, vidarabine 3%), oral acyclovir, and homatropine 1%.

Educational Objective:

Diagnose herpes conjunctivitis and keratitis.

Key Point:

Herpes keratitis is a vision-threatening condition caused by herpes simplex virus type 1 and herpes varicella-zoster virus infections. Vesicular lesions affecting the nose are associated with herpes zoster ophthalmicus. Diagnose cornea involvement with fluorescein staining.


Two herpesviruses–herpes simplex virus (HSV) and the herpes varicella-zoster virus (HZV)–are clinically important causes of viral conjunctivitis. Either virus can present as an isolated, superficial conjunctivitis that will mimic a “regular viral conjunctivitis,” in which corneal fluorescein staining will be normal and the classic dendritic branching pattern will be absent. Even the early stages of corneal involvement will show up as punctate lesions rather than a dendritic pattern on fluorescein staining, which can be confused with, for example, welder keratitis. Only the severe form of herpetic conjunctivitis (with either one of the herpes viruses) will present with the classic dendritic pattern on fluorescein staining.

The treatment regimens vary for each entity. For this reason, the physician should be able to discern “regular conjunctivitis” from HSV-related conjunctivitis, HZV-related conjunctivitis, HSV-related keratitis, and HZV-related keratitis. All forms of herpes ocular infection will resolve without treatment; the rationale of treatment is to minimize scarring. The figures show HSV-related keratitis (dendritic branching pattern with small terminal bulb is present), which is classified as a severe infection. This is treated with topical antivirals (ganciclovir might be less toxic to the epithelium than trifluridine and vidarabine), oral acyclovir, and a cycloplegic for pain relief. In this patient, the dendritic branching pattern gives away the diagnosis of HSV-related keratitis; the other pieces of history are irrelevant.

Acyclovir is not usually used to treat HZV infection, but it is used in HSV infections. The reverse holds true for steroids; they should not be prescribed for patients with HSV-related conjunctivitis because of the increased risk for secondary infection and other complications from uncontrolled viral proliferation. Steroids may at times be prescribed for severe HZV-related keratitis.


Bhatia K, Sharma R. Herpes zoster ophthalmicus. Emerg Med. 2013;26:209-225.

Janniger CK. Herpes zoster. Accessed December 6, 2017.

Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008;26(1):35-55, vi.

Barnes, Scott D, et al. Microbial keratitis. In: Mandell GL. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8th ed., 2015:1402-1414.

Wang J. Herpes simplex virus (HSV) keratitis. Accessed December 6, 2017.

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