A 32-year-old woman presents with a 5-day history of unilateral eye pain, photophobia, and blurred vision. On examination, the cornea shows a dendritic ulcer with terminal bulbs staining with fluorescein. Conjunctival injection and preauricular lymphadenopathy are noted. What is the most appropriate next step in management?

Question

Accepted Answer

B. Initiate topical acyclovir 5% ointment 5 times daily and oral acyclovir 400 mg 5 times daily for 10 days. ## Clinical Diagnosis The dendritic ulcer with terminal bulbs and fluorescein staining is pathognomonic for **herpes simplex virus (HSV) keratitis**. The constellation of unilateral pain, photophobia, and preauricular lymphadenopathy confirms the diagnosis. **Key Point:** Dendritic ulcer = HSV keratitis until proven otherwise. Do not delay treatment while awaiting culture results. ## Management Algorithm ```mermaid flowchart TD A[Dendritic ulcer on exam]:::outcome --> B{Confirmed HSV keratitis?}:::decision B -->|Yes - Epithelial disease| C[Topical acyclovir 5% ointment
5 times daily]:::action C --> D[Add oral acyclovir
400 mg 5 times daily × 10 days]:::action D --> E[Avoid topical steroids
in epithelial disease]:::urgent B -->|Stromal/endothelial involvement| F[Consider topical steroid
+ acyclovir after epithelial healing]:::action A --> G[Preauricular lymphadenopathy
is expected finding]:::outcome ``` ## Treatment Rationale **High-Yield:** HSV epithelial keratitis responds rapidly to topical acyclovir ointment. Oral acyclovir reduces recurrence risk and systemic viral load. | Drug | Indication | Dosing | Duration | |------|-----------|--------|----------| | Topical acyclovir 5% ointment | Epithelial HSV keratitis | 5 times daily | Until re-epithelialization (7–10 days) | | Oral acyclovir | Systemic suppression + epithelial disease | 400 mg 5× daily | 10 days | | Topical steroids | Stromal/endothelial disease ONLY | After epithelial healing | Avoid in epithelial phase | **Clinical Pearl:** Preauricular lymphadenopathy is a normal host response to HSV and does not indicate CNS involvement. It resolves with systemic antiviral therapy. **Warning:** Do NOT use topical steroids in epithelial HSV keratitis — they promote viral replication and cause geographic/amoeboid ulceration (herpes simplex keratouveitis). ## Why Immediate Treatment? 1. Epithelial HSV keratitis is self-limited but acyclovir accelerates healing (7–10 days vs. 2–3 weeks). 2. Early treatment reduces risk of stromal involvement and scarring. 3. Viral culture takes 5–7 days; clinical diagnosis is sufficient to initiate therapy. [cite:Khurana Comprehensive Ophthalmology Ch 3] ![Viral Keratitis diagram](https://mmcphlazjonnzmdysowq.supabase.co/storage/v1/object/public/blog-images/explanation/4140.webp)

Answer

A. Prescribe topical chloramphenicol 0.5% 4 times daily as empirical broad-spectrum cover

Answer

C. Refer to neurosurgery for evaluation of possible CNS involvement given the preauricular lymphadenopathy

Answer

D. Perform corneal scraping for viral culture and defer treatment until results are available

Explanation

Clinical Diagnosis

Management Algorithm

Treatment Rationale

Why Immediate Treatment?

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Drug	Indication	Dosing	Duration
Topical acyclovir 5% ointment	Epithelial HSV keratitis	5 times daily	Until re-epithelialization (7–10 days)
Oral acyclovir	Systemic suppression + epithelial disease	400 mg 5× daily	10 days
Topical steroids	Stromal/endothelial disease ONLY	After epithelial healing	Avoid in epithelial phase