Most common site of recurrent herpetic keratitis in a patient with previous HSV-1 infection is:

Question

Accepted Answer

D. Corneal epithelium. ## Most Common Site of Recurrent HSV Keratitis

**Key Point:** Recurrent herpetic keratitis most commonly affects the corneal epithelium, presenting as dendritiform or geographic ulcers. This is the initial site of viral reactivation and replication.

### Stratification of HSV Keratitis by Depth

| Layer | Type | Frequency | Clinical Features |
|-------|------|-----------|-------------------|
| **Epithelium** | Epithelial keratitis | Most common (60–70%) | Dendritiform ulcer, reduced sensation, rapid healing |
| **Stroma** | Stromal keratitis | 20–30% | Disc-shaped infiltrates, vascularization, scarring |
| **Descemet + Endothelium** | Endotheliitis | 5–10% | Keratic precipitates, anterior chamber reaction, Busacca nodules |

### Why Epithelium is the Recurrent Site

1. **Viral reactivation pathway:** Latent HSV in trigeminal ganglion → axonal transport to corneal nerve endings → epithelial infection
2. **Epithelial tropism:** HSV has highest replicative capacity in epithelial cells
3. **Accessibility:** Epithelium is the first barrier encountered by reactivating virus
4. **Rapid healing:** Epithelial defects heal within 7–10 days with topical antivirals

### Clinical Presentation of Epithelial Recurrence

**High-Yield:** Recurrent epithelial keratitis presents as:
- Dendritiform ulcer (classic branching pattern with terminal bulbs)
- Or geographic ulcer (larger, map-like ulcer from coalescence of dendrites)
- **Reduced corneal sensation** (distinguishes from bacterial or fungal keratitis)
- Unilateral, often in same eye as previous episode

### Stromal Involvement (Secondary)

**Clinical Pearl:** Stromal keratitis can develop as a sequela of epithelial infection (post-epithelial stromal keratitis) or as an immune-mediated response (immune stromal keratitis). It is less common in recurrent disease and suggests either:
- Inadequate epithelial healing
- Immune reactivation
- Chronic viral persistence

### Management Implications

- **Epithelial keratitis:** Topical acyclovir 5× daily; avoid topical steroids (risk of geographic ulcer)
- **Stromal keratitis:** Requires topical corticosteroids ± systemic antivirals (immune-mediated component)
- **Endotheliitis:** Topical steroids + systemic antivirals; monitor for graft rejection if post-transplant

**Warning:** Do not use topical corticosteroids alone in epithelial HSV keratitis—this causes geographic ulceration and worsening of epithelial disease. Always combine with antiviral therapy.

Answer

A. Corneal stroma

Answer

B. Descemet's membrane

Answer

C. Corneal endothelium

Most common site of recurrent herpetic keratitis in a patient with previous HSV-1 infection is:

Explanation

Most Common Site of Recurrent HSV Keratitis

Stratification of HSV Keratitis by Depth

Why Epithelium is the Recurrent Site

Clinical Presentation of Epithelial Recurrence

Stromal Involvement (Secondary)

Management Implications

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Layer	Type	Frequency	Clinical Features
Epithelium	Epithelial keratitis	Most common (60–70%)	Dendritiform ulcer, reduced sensation, rapid healing
Stroma	Stromal keratitis	20–30%	Disc-shaped infiltrates, vascularization, scarring
Descemet + Endothelium	Endotheliitis	5–10%	Keratic precipitates, anterior chamber reaction, Busacca nodules