A 28-year-old woman presents with severe left eye pain, photophobia, and blurred vision for 3 days. On examination, she has a dendritic ulcer on the cornea with fluorescein staining. She reports a history of recurrent oral cold sores. Anterior chamber shows mild inflammation. Which of the following is the most appropriate initial management?

Explanation

## Diagnosis: Herpes Simplex Virus (HSV) Keratitis **Key Point:** HSV-1 causes dendritic corneal ulcers — a pathognomonic finding characterized by branching epithelial defects that stain with fluorescein. The history of recurrent oral cold sores strongly supports HSV-1 as the causative agent. ## Management of HSV Epithelial Keratitis **High-Yield:** For **epithelial HSV keratitis** (dendritic ulcer), **topical antivirals alone** are the standard first-line treatment per established guidelines (AAO, Kanski's Clinical Ophthalmology, and Wills Eye Manual): - **Topical acyclovir 3% ointment** 5 times daily × 7–10 days, OR - **Topical ganciclovir 0.15% gel** 5 times daily, OR - **Topical trifluridine 1% drops** 9 times daily Systemic (oral) acyclovir is **NOT routinely required** for uncomplicated epithelial keratitis in an immunocompetent patient. Oral antivirals are reserved for: - Severe or recurrent disease - Immunocompromised patients - Stromal or endothelial keratitis - Herpetic eye disease with concurrent lid/conjunctival involvement - Prevention of recurrence (prophylaxis: 400 mg twice daily long-term) **Clinical Pearl:** Topical ointment formulations (acyclovir 3%) maintain better corneal contact time and drug penetration compared to drops, making them preferred for epithelial disease. The combination of topical + systemic therapy is not standard for routine epithelial keratitis in an immunocompetent host. ## Why Other Options Are Wrong | Option | Reason Incorrect | |--------|-----------------| | B) Topical + oral acyclovir | Oral acyclovir not routinely indicated for uncomplicated epithelial keratitis in immunocompetent patients | | C) Topical corticosteroids | **CONTRAINDICATED** in acute HSV epithelial keratitis — promotes viral replication, geographic ulcer expansion, stromal melting, and perforation | | D) Topical antibiotics | Not indicated; HSV keratitis is viral, not bacterial; antibiotics do not treat the underlying cause | **Warning:** Corticosteroids are only considered (with antiviral cover) in **immune stromal keratitis** — NEVER in active epithelial disease. **Reference:** Kanski's Clinical Ophthalmology, 9th ed.; Wills Eye Manual, 7th ed.; HEDS (Herpetic Eye Disease Study) trials — oral acyclovir did not reduce recurrence of stromal keratitis when added to topical steroids in epithelial disease management.