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:

Explanation

## 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).