A 32-year-old woman presents with unilateral eye pain, photophobia, and blurred vision for 3 days following a vesicular rash on the forehead. Slit-lamp examination reveals dendritic ulcers with terminal bulbs on the cornea and anterior uveitis. Regarding HSV keratitis, all of the following are true EXCEPT:

Question

Accepted Answer

A. Topical acyclovir is contraindicated and should be avoided in all cases of HSV keratitis. ## Distinguishing True from False Statements in HSV Keratitis

### Correct Statements (Options 0, 2, 3)

**Key Point:** Recurrent HSV keratitis is indeed more common than primary infection because the virus remains latent in the trigeminal ganglion and reactivates with triggers (stress, UV exposure, immunosuppression).

**High-Yield:** Stromal keratitis in HSV is fundamentally an immune-mediated process driven by T-cell responses and immune complex deposition, NOT active viral replication. This is why topical antivirals alone are insufficient; topical corticosteroids are often required.

**Clinical Pearl:** Recurrent HSV keratitis episodes lead to cumulative corneal damage, including scarring, neovascularization, and permanent vision loss if untreated.

### The False Statement (Option 1)

**Warning:** Topical acyclovir is NOT contraindicated in HSV keratitis — it is the **standard of care** for epithelial keratitis and is used as adjunctive therapy in stromal disease. The statement is categorically incorrect.

| Aspect | Detail |
|--------|--------|
| **Epithelial HSV keratitis** | Topical acyclovir 5 times daily ± topical antibiotic |
| **Stromal HSV keratitis** | Topical acyclovir + topical corticosteroids (to reduce inflammation) |
| **Endotheliitis** | Topical acyclovir + topical steroids; consider systemic acyclovir |

**Mnemonic:** **SHES** — **S**tromal, **H**erpes, **E**ndothelial, **S**teroids needed (along with antivirals).

Answer

B. Corneal scarring and neovascularization are potential sequelae of recurrent episodes

Answer

C. Recurrent HSV keratitis is more common than primary infection

Answer

D. Stromal keratitis is associated with immune-mediated inflammation rather than viral replication

Explanation

Distinguishing True from False Statements in HSV Keratitis

Correct Statements (Options 0, 2, 3)

The False Statement (Option 1)

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Aspect	Detail
Epithelial HSV keratitis	Topical acyclovir 5 times daily ± topical antibiotic
Stromal HSV keratitis	Topical acyclovir + topical corticosteroids (to reduce inflammation)
Endotheliitis	Topical acyclovir + topical steroids; consider systemic acyclovir