Ocular herpes – Ulcer, herpetic keratitis and uveitis
Herpes is a viral infection that can affect various parts of the body, including the eyes, with varying degrees of severity. Depending on the virus strain, its manifestations can affect the genitals, mouth, face, or, in the most serious cases, the brain. Ocular herpes is the leading cause of infectious monocular blindness in developed countries. Ocular herpes lesions are similar to those caused by ophthalmic zoster (shingles) because both viruses belong to the same family. However, ocular herpes is more common and affects younger patients, while ophthalmic shingles is rarer and tends to affect older or immunocompromised individuals.
What is ocular herpes?
Ocular herpes refers to the set of ocular manifestations of herpes reactivations.
As with cold sores, we can have outbreaks of herpes, but in the eye.
Even more serious, they often affect the same eye.
The most common strain is HSV 1.
A viral infection
There are two strains of the herpes virus. Herpes simplex virus type 1 (HSV1) is the most common strain, with a tropism for the oronasal and facial areas. HSV1 is the strain responsible for ocular infections.
The virus is usually contracted in childhood during a first episode (primary infection) which most often goes unnoticed.
In 6% of cases, this primary infection manifests as benign gingivostomatitis (vesicles and aphthae in the mouth), which heals in a few days.
Then, the virus lies dormant in the body and the patient does not show any symptoms.
Then, in certain circumstances during life (fatigue, stress, intercurrent illness, sunstroke, fever, premenstrual period or general decline in immunity), the virus will reactivate, causing an "outbreak" that will affect the lips (herpes labialis or "cold sore"), eyelids, eye or brain.
It is estimated that between 70 and 90% of adults in France carry HSV1. However, the infection is only contagious through direct contact with the saliva, tears, or "cold sore" of a person experiencing an outbreak.
Herpes simplex type 2 (HSV2), less common, has a predominantly genital tropism. It is a sexually transmitted infection, unlike HSV1.
HSV2 is therefore not generally involved in ocular damage, and its estimated prevalence in France is around 15% to 20% in the adult population.
After the phase of contamination through unprotected sexual intercourse with an individual in the midst of an outbreak, symptoms appear in one third of cases (painful vesicles in the genital area), the patient recovers under treatment in about ten days.
Subsequently, the infection remains latent in the body and progresses through recurrent outbreaks, triggered by the same factors as HSV 1.
Ocular herpes is therefore due to recurrences of HSV1, which can cause several different lesions on the eyelid and eye: the symptoms will therefore vary depending on the lesion caused.
However, the common characteristic of the different herpes symptoms is that they develop in recurrent outbreaks, and always affect the same eye: having herpes in both eyes is very rare (about 1% of cases)!
Forms of ocular herpes
Eyelid herpes
Eyelid herpes causes clusters of small white blisters most often in the inner corner of the upper eyelid, accompanied by moderate pain, a burning sensation and itching.
It is essential not to scratch them, at the risk of superinfection with staphylococcus aureus (transformation into impetigo, or even eyelid cellulitis).
Herpetic conjunctivitis
Herpetic conjunctivitis causes a moderately red, slightly painful but pruritic (itchy) eye, with dirty discharge and the eye sticking together in the morning.
This conjunctivitis, with manifestations similar to those of any viral conjunctivitis, however only affects one eye at a time.
Herpetic keratitis
Herpetic keratitis is by far the most common manifestation of ocular herpes. It is a keratitis (the subject of this article) causing localized redness around the cornea (perikeratic circle), tearing, pain with a sensation of a foreign body under the upper eyelid when blinking, and photophobia (difficulty tolerating light, forcing the eyes to remain closed).
A decrease in visual acuity is not systematic. In cases of frequent recurrences or severe keratitis, corneal scarring may persist after flare-ups, leading to permanent visual acuity loss.
Herpetic anterior uveitis
Herpetic anterior uveitis is a form of acute anterior uveitis.
It can be isolated or associated with keratitis at the same time (this is then called kerato-uveitis), generally resulting in an eye with more marked redness, with more intense pain and photophobia.
A decrease in visual acuity is almost systematic.
Herpetic posterior uveitis
Herpetic posterior uveitis is fortunately rarer, but constitutes the most serious form of herpetic eye disease, since it can progress to retinal necrosis (permanent loss of vitality of the retina, which leads to a severe decrease in visual acuity).
Affected patients complain of floaters (perception of shadows or flies in the field of vision), photophobia, and unilateral decreased visual acuity. The eye may be red and painful, or not.
Patients with severe immunosuppression (AIDS) are at greater risk because they have more severe retinal damage… But few symptoms at the start, which often explains a delay in diagnosis.
Without prompt treatment, posterior uveitis can spread to the other eye.
What to do in case of ocular herpes
Diagnosis or suspicion of ocular herpes by the patient themselves is easy in three circumstances:
Observations of vesicles on the eyelids
History of herpes on the same eye
Red, irritated eye accompanying a cold sore.
The main risk is the worsening of the condition due to a delay in treatment or self-medication by the patient.
Self-medication & natural treatment – Risk of complications and treatment delays
Attempting to treat a red eye yourself without consulting a doctor, or refusing prescribed treatments, can lead to serious complications:
Bacterial superinfection of an eyelid leads to impetigo, or even palpebral cellulitis (deep infection of the entire eyelid).
Bacterial superinfection of keratitis leads to a corneal abscess, which takes longer to treat and can leave corneal scars resulting in permanent vision loss.
In the case of uveitis, delayed treatment can lead to optic nerve damage if intraocular pressure increases, or can cause damage to the cornea, iris, or lens, resulting in impaired visual quality.
Finally, the patient must absolutely avoid self-administering any treatment without consulting an ophthalmologist. In particular, the instillation of corticosteroid eye drops is strictly contraindicated as it can rapidly worsen herpetic keratitis.
Place of the ophthalmology consultation
An ophthalmological consultation is mandatory and will specify exactly the nature of the herpetic infection in order to prescribe appropriate treatment, which differs depending on the patient's condition: anti-herpetic tablets, cycloplegic eye drops, healing ointment, corticosteroid eye drops or ointment.
The ophthalmologist will then recommend regular follow-up appointments, which are essential to ensure proper visual recovery. In cases of frequent recurrence, the doctor may also suggest preventative treatment to limit the symptoms of relapse.
Treatment
The treatment of ocular herpes relies primarily on oral antiviral medications (tablets). Valacyclovir and acyclovir are the standard treatments.
The earlier treatment is introduced, the better the prognosis! Consultation and treatment must be carried out urgently.
The rest of the treatment focuses on managing the condition:
Healing eye drops and ointment for ulcers.
Anti-inflammatory drops for uveitis.
Antiseptics in case of corneal superinfection.
Antiviral drops or ointments are no longer indicated except for herpetic keratitis in patients with severe renal insufficiency. Consequently, acyclovir ointment may be virtually banned from medical practice.
Conclusion
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Ocular herpes is a common condition that remains dormant in the body for life. Certain circumstances lead to more or less frequent recurrences, with ocular involvement that can threaten medium- and long-term vision.
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It is important to pay close attention to the first symptoms, especially if you have a personal history of herpes. Prompt consultation with an ophthalmologist and regular follow-up are therefore essential to avoid serious consequences of this condition.