How do you tell the difference between a corneal ulcer and a Herpes simplex. The Herpes does not necessarily have to to end bulbs.

[Ken Bova]

How do yu tell the difference between a corneal ulcer and a Herpes simplex. The Herpes simplex does not necessarly have to have end bulbs

 

[Charles A McBride]

One is full of PMN's. One mostly just stains. What are you getting at? -Charlie

 

[Tom Vaxmonsky OD]

cool coincidence but just had one yesterday that didn't appear herpetic at all, just a large pool of NaFl in a generally oblong shape that I initiated q1h Besivance and then today filled in with enough epithelium to make the branches and bulbs somewhat apparent throughout

should've taken pictures and you'd have thought Dr Bova sent the patient to me , how far is Uniontown from me?

slowed the Besivance frequence and added antiviral orals and will see how it goes

funny thing is yesterday she said she started to treat her "abrasion" with some of the bottle of drops with the brown cap she'd been given every time before but then noticed it was expired so made the appointment to see me to get a new bottle,,,, so likely this wasn't her first herpetic "abrasion"

 

[Mike Alvarez]

Non herpetic corneal ulcers are much more painful and generally have a more acute onset. With a bacterial ulcer, they’ll say, “It started yesterday”. With herpes it’s often, “My eyes been bugging me for the past week or so…..”

Also, of course, bacterial ulcers have infiltrates.

 

[Laurence Craig Thomas]

Dr. Bova,

First, please let me apologize for the harsh and profane comments that I directed towards you many months ago regarding one of your posts. It was inappropriate and I will not insult you again. Also, thanks for not blocking me after my outburst.

Regarding your question, there is an excellent article in the September 2011 issue of Review of Optometry that answers practically any question you could have on this topic. It is entitled Bacterial vs. Viral: Name That Infection! and was written by Aaron Bronner, OD.

I just finished reading the piece and it is an excellent reference to learn or re-learn about the differential diagnosis of these two very different conditions.

As my friend Tom has correctly pointed out, these lesions can be similar in appearance until the clinical presentation gets worse. In other words, the pre-dendritic stage of herpes simplex is often overlooked or vague enough to create clinical confusion.

To quote from the article:

"Unfortunately, what we see more often are non-specific findings, such as injection, minimal mucous discharge, papillae or follicles (or both) and some degree of corneal infiltration, running the gamut from diffuse stromal white blood cells to a dense focal area of infiltration either with or without an overlying epithelial defect. When faced with non-specific findings, it is up to us to come to a reasonable diagnosis and form an appropriate treatment plan."

After I read the article, I was reminded of the specific regions of the cornea that play a role in the immune response to infection. In my own Review of Optometry article entitled Understanding Specular Microscopy from several years ago, I touched on the differences in endothelial anatomy between the central corneal region and the peripheral corneal region. Well, the cornea also has two distinct immunologic regions - the limbal/peripheral zone and the central zone.

The location-dependent duality of corneal immunity is the source of some fairly common differences between lesions of the periphery and lesions of the paracentral zone. For example, when the ulcer is caused by the herpes virus, if the insult is at or near the corneal periphery, the proximity to the limbus allows the immune system to more effectively contain viral activity and the characteristic dendritic appearance never develops or it may be obscured by any type of corneal infiltration.

I believe that is an important piece of information to assist in your medical decision-making.

I could go on and on, but I would simply encourage any optometrist that wants to be well-read on the question that Dr. Bova posed to just read the article and go from there...

This is a picture from one of my patients with herpes simplex. The presentation can change depending on the stage of the disease and the patient's response to treatment.

 

[Lloyd Pate]

Corneal sensitivity
Rose Bengal stain

 

[Mike Alvarez]

Corneal sensitivity
Rose Bengal stain

What about lisimine green?

 

[Lloyd Pate]

What about lisimine green?

https://iovs.arvojournals.org/article.aspx?articleid=2123152

 

[Charles A McBride]

Dr. Bova,

First, please let me apologize for the harsh and profane comments that I directed towards you many months ago regarding one of your posts. It was inappropriate and I will not insult you again. Also, thanks for not blocking me after my outburst.

Regarding your question, there is an excellent article in the September 2011 issue of Review of Optometry that answers practically any question you could have on this topic. It is entitled Bacterial vs. Viral: Name That Infection! and was written by Aaron Bronner, OD.

I just finished reading the piece and it is an excellent reference to learn or re-learn about the differential diagnosis of these two very different conditions.

As my friend Tom has correctly pointed out, these lesions can be similar in appearance until the clinical presentation gets worse. In other words, the pre-dendritic stage of herpes simplex is often overlooked or vague enough to create clinical confusion.

To quote from the article:

"Unfortunately, what we see more often are non-specific findings, such as injection, minimal mucous discharge, papillae or follicles (or both) and some degree of corneal infiltration, running the gamut from diffuse stromal white blood cells to a dense focal area of infiltration either with or without an overlying epithelial defect. When faced with non-specific findings, it is up to us to come to a reasonable diagnosis and form an appropriate treatment plan."

After I read the article, I was reminded of the specific regions of the cornea that play a role in the immune response to infection. In my own Review of Optometry article entitled Understanding Specular Microscopy from several years ago, I touched on the differences in endothelial anatomy between the central corneal region and the peripheral corneal region. Well, the cornea also has two distinct immunologic regions - the limbal/peripheral zone and the central zone.

The location-dependent duality of corneal immunity is the source of some fairly common differences between lesions of the periphery and lesions of the paracentral zone. For example, when the ulcer is caused by the herpes virus, if the insult is at or near the corneal periphery, the proximity to the limbus allows the immune system to more effectively contain viral activity and the characteristic dendritic appearance never develops or it may be obscured by any type of corneal infiltration.

I believe that is an important piece of information to assist in your medical decision-making.

I could go on and on, but I would simply encourage any optometrist that wants to be well-read on the question that Dr. Bova posed to just read the article and go from there...

This is a picture from one of my patients with herpes simplex. The presentation can change depending on the stage of the disease and the patient's response to treatment.

View attachment 34795

This is such a good post, as we are so fortunate to so frequently receive from LCT. I didn't know about the likely limitation, other than the larger surface area, of dendrites to form more peripherally. Thank you, once again, for the education. It's what makes connecting in this way so important for all of us.

I don't mean to misdirect the thread in any way, but I can't help but share a very recent case of uveitis that I initially treated with steroids.

My young partner, who is strong already and getting stronger each second, ordered all the labs for my patient looking for autoimmune disease. All negative. (And she paid all the bills yesterday too, another topic.)

Anyway, the patient developed corneal dendrites (non-central!), which, although not certain, likely indicated a preceding viral uveitic etiology.

A reminder to be on the lookout. -Charlie

 

[Lloyd Pate]

Myron Yanoff, Douglas Cameron, in Goldman's Cecil Medicine (Twenty Fourth Edition), 2012

Herpes Simplex Keratitis​

Herpes simplex keratitis is the most common cause of central corneal ulcer (Fig. 431-19)

 

[Lloyd Pate]

Infectious Diseases 4th Edition 2017
Conjunctivitis, keratitis, and infections of periorbital structures

"Recurrence occurs in around 10% of cases at 1 year and 50% by 20 years. Triggers include fever, trauma, surgery and ultraviolet light. Recurrence is a consequence of latency.40 Typical presentation is central corneal dendritic ulcers without infiltration easily seen with fluoresceine test. "

 

[Jeff Guthrie]

There can be a wide range of presentations for HSV keratitis and it is also possible to have concurrent viral and bacterial infections that cause more significant disease. If in doubt there's nothing wrong with combining topical antibiotics + oral antivirals.

 

[Matt Judd]

as Lloyd mentions, always check cornea sensitivity before instilling any anesthetic. If they jump out of the chair, you likely
do not have HSV.

For me they are very different presentations. HZV as well. classic HSV youll probably never miss with the bulbs etc

 

[Charles A McBride]

as Lloyd mentions, always check cornea sensitivity before instilling any anesthetic. If they jump out of the chair, you likely
do not have HSV.

For me they are very different presentations. HZV as well. classic HSV youll probably never miss with the bulbs etc

Would a patient with recurrent bouts of HSK no longer present primarily with symptoms of pain? -Charlie

 

[Matt Judd]

Would a patient with recurrent bouts of HSK no longer present primarily with symptoms of pain? -Charlie

I would say....yes.

 

[Lloyd Pate]

I would say....yes.

Yes, the pain decreases as the nerves are damaged.

 

[Mike Alvarez]

Yes, the pain decreases as the nerves are damaged.

Even with the first infection a dendrite is nowhere near as painful as a bacterial ulcer. I recently saw a kid come in for “pink eye” that wasn’t getting better after a week on the maxitrol prescribed by his pediatrician. He had 12 dendrites and just complained of an irritated, red eye.

 

[Lloyd Pate]

Even with the first infection a dendrite is nowhere near as painful as a bacterial ulcer. I recently saw a kid come in for “pink eye” that wasn’t getting better after a week on the maxitrol prescribed by his pediatrician. He had 12 dendrites and just complained of an irritated, red eye.

Correct. That is why you check corneal sensitivity to help your diagnosis. The virus lives and reproduces in the nerves, so they are compromised from the start. It is similar to rabies.

 

[Scott Blahnik]

https://iovs.arvojournals.org/article.aspx?articleid=2123152

So use both?

Figure 1.
[IMG alt="Keratitis induced by HSV-1 strain H129 at 7 dpi stained with lissamine
green B (A) or rose bengal (B) ophthalmic dyes.
Lissamine green B (A) stains the large geographic lesions as
well as the punctate and dendritic lesions (arrows). Rose
bengal (B) stained the periphery of the geographic lesion
shown (bounded by arrows), but only poorly stained the
center area. Note that the corneal lesion in the rose bengal–treated
eye (B) is smaller and less conspicuous than in the
lissamine green B–treated eye (A)."]https://arvo.silverchair-cdn.com/ar...a0bw__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA[/IMG]
View OriginalDownload Slide

Keratitis induced by HSV-1 strain H129 at 7 dpi stained with lissamine green B (A) or rose bengal (B) ophthalmic dyes. Lissamine green B (A) stains the large geographic lesions as well as the punctate and dendritic lesions (arrows). Rose bengal (B) stained the periphery of the geographic lesion shown (bounded by arrows), but only poorly stained the center area. Note that the corneal lesion in the rose bengal–treated eye (B) is smaller and less conspicuous than in the lissamine green B–treated eye (A).

 

[Dr. Stanley Hallock]

I try to remember that Herpes can look like anything. An older non-contact lens Patient with a rather nondescript epithelial lesion/ulcer - who is not a kidney Patient - would not be harmed by the Doc covering-that-base by adding some Valtrex at the same time as the topical antibiotic on an aggressive schedule [take your pick > Moxifloxacin Besivance Tobramycin]

 

[Ken Bova]

Dr. Bova,

First, please let me apologize for the harsh and profane comments that I directed towards you many months ago regarding one of your posts. It was inappropriate and I will not insult you again. Also, thanks for not blocking me after my outburst.

Regarding your question, there is an excellent article in the September 2011 issue of Review of Optometry that answers practically any question you could have on this topic. It is entitled Bacterial vs. Viral: Name That Infection! and was written by Aaron Bronner, OD.

I just finished reading the piece and it is an excellent reference to learn or re-learn about the differential diagnosis of these two very different conditions.

As my friend Tom has correctly pointed out, these lesions can be similar in appearance until the clinical presentation gets worse. In other words, the pre-dendritic stage of herpes simplex is often overlooked or vague enough to create clinical confusion.

To quote from the article:

"Unfortunately, what we see more often are non-specific findings, such as injection, minimal mucous discharge, papillae or follicles (or both) and some degree of corneal infiltration, running the gamut from diffuse stromal white blood cells to a dense focal area of infiltration either with or without an overlying epithelial defect. When faced with non-specific findings, it is up to us to come to a reasonable diagnosis and form an appropriate treatment plan."

After I read the article, I was reminded of the specific regions of the cornea that play a role in the immune response to infection. In my own Review of Optometry article entitled Understanding Specular Microscopy from several years ago, I touched on the differences in endothelial anatomy between the central corneal region and the peripheral corneal region. Well, the cornea also has two distinct immunologic regions - the limbal/peripheral zone and the central zone.

The location-dependent duality of corneal immunity is the source of some fairly common differences between lesions of the periphery and lesions of the paracentral zone. For example, when the ulcer is caused by the herpes virus, if the insult is at or near the corneal periphery, the proximity to the limbus allows the immune system to more effectively contain viral activity and the characteristic dendritic appearance never develops or it may be obscured by any type of corneal infiltration.

I believe that is an important piece of information to assist in your medical decision-making.

I could go on and on, but I would simply encourage any optometrist that wants to be well-read on the question that Dr. Bova posed to just read the article and go from there...

This is a picture from one of my patients with herpes simplex. The presentation can change depending on the stage of the disease and the patient's response to treatment.

View attachment 34795

Laurence, I have no memory of your insulting me, but thanks for the apology. Your response was most informative and I will be sure to look up Sept. 2011 issue.

 

[Ken Bova]

cool coincidence but just had one yesterday that didn't appear herpetic at all, just a large pool of NaFl in a generally oblong shape that I initiated q1h Besivance and then today filled in with enough epithelium to make the branches and bulbs somewhat apparent throughout

should've taken pictures and you'd have thought Dr Bova sent the patient to me , how far is Uniontown from me?

slowed the Besivance frequence and added antiviral orals and will see how it goes

funny thing is yesterday she said she started to treat her "abrasion" with some of the bottle of drops with the brown cap she'd been given every time before but then noticed it was expired so made the appointment to see me to get a new bottle,,,, so likely this wasn't her first herpetic "abrasion"

Not very far. My location borders Ohio, WV, and Maryland.

 

[Ken Bova]

There can be a wide range of presentations for HSV keratitis and it is also possible to have concurrent viral and bacterial infections that cause more significant disease. If in doubt there's nothing wrong with combining topical antibiotics + oral antivirals.

Jeff, that what a corneal specialist told me last year.

 

[Matt Judd]

the truly difficult one...fungal. difficult to diagnose sometimes. takes forever to culture. can look like anything. satellite
lesions raise the suspicion. Very difficult to treat.

 

[William Roy Shouldice]

There can be a wide range of presentations for HSV keratitis and it is also possible to have concurrent viral and bacterial infections that cause more significant disease. If in doubt there's nothing wrong with combining topical antibiotics + oral antivirals.

this is my Friday protocol when pt does not want to come back in Saturday ( ice fishing or being on the boat usually trumps stand of care for most of my pts, especially if a nice day)...honestly everytime I think pt might need to be on valtrex I just do it now..simplex or zoster...unless kidney dx

 

[Mark Welding OD]

this is my Friday protocol when pt does not want to come back in Saturday ( ice fishing or being on the boat usually trumps stand of care for most of my pts, especially if a nice day)...honestly everytime I think pt might need to be on valtrex I just do it now..simplex or zoster...unless kidney dx

100% agree!!

 

[Nick Weber]

Current apparent HSK case in office for 2 visits. 55 yo WM.

approx. 10 years ago - History of acanthamoeba ulcer and significant thinning and scarring nasally in one eye. Scar has not affected vision. Since then he had an apparent HSK bout in this eye before I came to this clinic.
He shows up a week ago with obvious dendritic (with end bulbs) ulcer formation within the limits of this scar. I start him on Famvir 250 tid.
He returned today with more diffuse staining of the dendritic lesions and the bulbs. He feels somewhat better, but is not recovering as quickly as I had expected. I wonder if the scar that the ulcer lies within is restricting the ability of the Famvir to access the affected dendritic area? I added tobradex just to help with his discomfort and to help with possible bacterial coincidental infection (as he is kind of crusty.

Will see him at a week, and figure if he is not improving I may try Zirgan.

Any thoughts?

 

[Mark Welding OD]

Current apparent HSK case in office for 2 visits. 55 yo WM.

approx. 10 years ago - History of acanthamoeba ulcer and significant thinning and scarring nasally in one eye. Scar has not affected vision. Since then he had an apparent HSK bout in this eye before I came to this clinic.
He shows up a week ago with obvious dendritic (with end bulbs) ulcer formation within the limits of this scar. I start him on Famvir 250 tid.
He returned today with more diffuse staining of the dendritic lesions and the bulbs. He feels somewhat better, but is not recovering as quickly as I had expected. I wonder if the scar that the ulcer lies within is restricting the ability of the Famvir to access the affected dendritic area? I added tobradex just to help with his discomfort and to help with possible bacterial coincidental infection (as he is kind of crusty.

Will see him at a week, and figure if he is not improving I may try Zirgan.

Any thoughts?

I would have done zirgan than tobradex.

 

[Richard Pagan]

zirgan is very effective IMO, and I would not use tobradex for epithelial disease

 

[William Roy Shouldice]

Not a Famvir fan for simplex..prefer big boys valtrex..like 1000 mg bid or tid. Wondering if a bigger dose of Famvir would have done the trick? Zirgan is mucho expensive

 

[Matt Judd]

I'd probably culture this one. if they walk in and hand you a red flag, accept it, and proceed accordingly.

 

[Nick Weber]

Thanks, I'll see where he is on the other side of the weekend. I figure at least he will feel a little better. LOL.