Regarding the clinical presentations and management of different forms of viral keratitis, all of the following statements are correct EXCEPT:

Question

Accepted Answer

B. Topical corticosteroids are the first-line treatment for acute epithelial HSV keratitis and should be initiated immediately upon diagnosis. ## Viral Keratitis: Clinical Features and Treatment Principles

### Correct Statements (Options 0, 1, 3)

**High-Yield:** Adenoviral keratitis is notorious for subepithelial infiltrates that persist long after the epithelial defect heals, causing prolonged photophobia and foreign body sensation. These infiltrates are immune-mediated and may take weeks to months to resolve.

**Clinical Pearl:** VZV keratitis follows the distribution of the affected trigeminal division (V1 most common). The characteristic dermatomal vesicular rash precedes or accompanies ocular involvement, and corneal involvement may be sectoral or multifocal.

**Key Point:** Enteroviral keratitis (including EV-71 from hand-foot-and-mouth disease) typically causes mild, superficial punctate keratitis that resolves spontaneously without scarring or long-term sequelae.

### The False Statement (Option 2)

**Warning:** Topical corticosteroids are **NOT** first-line for acute epithelial HSV keratitis — they are **contraindicated** in the acute phase because they promote viral replication and geographic/amoeboid spread of the ulcer.

**Mnemonic:** **AAEV** — **A**cyclovir **A**lways **E**pithelial **V**iral keratitis (NOT steroids).

| Stage of HSV Keratitis | First-Line Treatment | Role of Steroids |
|------------------------|----------------------|------------------|
| **Epithelial** | Topical acyclovir 5×/day ± lubricants | Contraindicated (risk of spread) |
| **Stromal** | Topical acyclovir + topical steroids | Essential (reduce inflammation) |
| **Endotheliitis** | Topical acyclovir + topical steroids ± systemic acyclovir | Essential (reduce anterior uveitis) |

**Clinical Pearl:** Steroids are only introduced in stromal or endothelial disease once epithelial healing is confirmed, to suppress immune-mediated inflammation without risking viral dissemination.

Answer

A. Varicella-zoster virus keratitis is typically preceded by a dermatomal vesicular rash and may present with sectoral involvement corresponding to the affected trigeminal division

Answer

C. Enteroviral keratitis (e.g., EV-71) may present with superficial punctate keratitis and is often self-limited, resolving without scarring

Answer

D. Adenoviral keratitis presents with subepithelial infiltrates that may persist for months and cause photophobia despite resolution of epithelial disease

Regarding the clinical presentations and management of different forms of viral keratitis, all of the following statements are correct EXCEPT:

Explanation

Viral Keratitis: Clinical Features and Treatment Principles

Correct Statements (Options 0, 1, 3)

The False Statement (Option 2)

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Stage of HSV Keratitis	First-Line Treatment	Role of Steroids
Epithelial	Topical acyclovir 5×/day ± lubricants	Contraindicated (risk of spread)
Stromal	Topical acyclovir + topical steroids	Essential (reduce inflammation)
Endotheliitis	Topical acyclovir + topical steroids ± systemic acyclovir	Essential (reduce anterior uveitis)