Regarding the clinical features and management of Herpes Simplex Virus (HSV) keratitis, all of the following statements are correct EXCEPT:

Explanation

## Correct Answer Analysis **Key Point:** Dendritic ulcers are NOT pathognomonic for primary HSV infection — they represent the hallmark presentation of epithelial HSV keratitis and can occur in both primary and recurrent infections. Recurrent episodes are common and may present as identical dendrites or progress to more severe forms. ## HSV Keratitis: Clinical Forms & Features | Feature | Epithelial Keratitis | Stromal Keratitis | Endotheliitis | |---------|----------------------|-------------------|---------------| | **Presentation** | Dendritic or geographic ulcers | Stromal infiltration, neovascularization | Keratic precipitates, anterior chamber reaction | | **Recurrence** | Common (50% within 5 years) | Less common, immune-mediated | Associated with chronic infection | | **Sensation** | Reduced corneal sensation | Reduced sensation | Normal to reduced | | **Staining** | Fluorescein (ulcer base) | Rose Bengal (infected cells) | Minimal ulceration | **High-Yield:** Dendritic ulcers have a **branching pattern with terminal bulbous swellings** — this is the classic description. However, they are NOT unique to primary infection; recurrent HSV commonly presents with identical dendrites or geographic ulcers (coalescence of dendrites). ## Management Hierarchy 1. **Epithelial HSV keratitis** → Topical acyclovir 5 times daily (or ganciclovir, trifluridine) 2. **Stromal HSV keratitis** → Topical corticosteroids + systemic acyclovir (immune-mediated; steroids reduce inflammation) 3. **Endotheliitis** → Topical + systemic antivirals; corticosteroids if severe **Clinical Pearl:** Recurrent HSV keratitis in immunocompromised patients may present as **geographic ulcers** (large, irregular ulcers with scalloped borders) rather than dendrites — this represents coalescence and progression, not a different pathogen. **Warning:** Do NOT use topical corticosteroids alone in epithelial HSV keratitis — risk of geographic ulcer formation and corneal perforation. Always combine with antivirals.