## Management of Dendritic Keratitis (HSV-1) **Key Point:** Dendritic ulcer with terminal bulbs is pathognomonic for HSV keratitis and requires immediate antiviral therapy without waiting for culture confirmation. ### Rationale for Correct Answer The clinical presentation—vesicular rash on forehead (V1 distribution), dendritic ulcer with terminal bulbs, and anterior chamber reaction—is diagnostic of HSV-1 keratitis. The combination of topical acyclovir (5 times daily) and oral acyclovir (400 mg five times daily) is the gold standard first-line treatment. **High-Yield:** Dendritic ulcers are caused by viral replication in infected epithelial cells and are best managed with immediate antiviral therapy to prevent progression to geographic ulcers and stromal involvement. ### Why Immediate Treatment is Critical 1. **Epithelial keratitis** (dendritic stage) responds excellently to antivirals if started early 2. Delayed treatment risks progression to: - Geographic ulcers (coalescence of dendrites) - Stromal keratitis (immune-mediated, may require steroids later) - Endotheliitis and anterior uveitis **Clinical Pearl:** The terminal bulbs at the dendrite tips are sites of active viral replication and are diagnostic for HSV rather than VZV (which presents with more punctate epithelial keratitis). ### Treatment Duration - Topical acyclovir: Continue until complete epithelial healing (typically 7–10 days) - Oral acyclovir: Continue for 7–10 days to reduce recurrence risk - Prophylactic oral acyclovir (400 mg BD) may be considered for 6–12 months in recurrent cases **Mnemonic:** **DASH** = **D**endritic ulcer → **A**ntiviral → **S**tart immediately → **H**eal in 7–10 days [cite:Kanski 9e Ch 4] 
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