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Herpes Simplex Keratitis Workup

  • Author: Jim C Wang (王崇安), MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Dec 07, 2015
 

Approach Considerations

Herpes simplex virus (HSV) keratitis remains primarily a clinical diagnosis based on characteristic features of the corneal lesion.[1] Laboratory studies may help to confirm the clinical suspicion in cases lacking typical findings, but they are not readily available in most clinical settings.

If the diagnosis is in doubt, however, laboratory diagnosis can be made using the following[2] :

  • Giemsa stain - Scrapings of the corneal or skin lesions show multinucleated giant cells
  • Papanicolaou stain - This shows intranuclear eosinophilic inclusion bodies
  • Viral culture
  • Immunohistochemistry looking for viral antigens
  • Polymerase chain reaction (PCR) assay [3]
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Laboratory Studies

Epithelial scrapings with Giemsa stain may show multinucleated giant cells, resulting from coalescence of infected corneal epithelial cells and intranuclear viral inclusions. However, negative cytology results do not exclude HSV infection.

Viral cultures obtained within several days of onset of disease and prior to antiviral therapy have a sensitivity of up to 70% and also allow for identification of the HSV subtypes. Various techniques (eg, conventional tube culture, shell vial assay, suspension infection method) are available.

HSV-antigen detection tests, such as the enzyme-linked virus-inducible system (ELVIS), are very specific for detecting herpes infection, but they are limited by their lower sensitivity. Cell culture for confirmation of HSV is recommended when the ELVIS test result is negative.

PCR assay using tear samples, corneal epithelium, anterior chamber tap, or corneal buttons may detect viral DNA in cases of herpetic keratitis or keratouveitis. However, it does not distinguish between latent or active HSV infections.

A study by Inoue et al indicated that an immunochromatographic assay (ICGA) kit developed for the identification of HSV is clinically useful in the diagnosis of HSV epithelial keratitis. The investigators found that the ICGA had moderate sensitivity and high specificity, showing positive results for 35 out of 75 patients (46.7%) diagnosed with epithelial keratitis and negative results for 39 out of 39 patients (100%) who did not have the disease.[19]

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Imaging Studies

Slit-lamp photography may be used to document disease progression and response to treatment.

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Contributor Information and Disclosures
Author

Jim C Wang (王崇安), MD Vitreo-Retinal and Cornea/Anterior Segment Subspecialist, Department of Ophthalmology, Kaiser Permanente Fontana Medical Center

Jim C Wang (王崇安), MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

David C Ritterband, MD, FACS Assistant Director of Cornea Service, New York Eye and Ear Infirmary; Clinical Professor of Ophthalmology, Icahn School of Medicine at Mount Sinai

David C Ritterband, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, Association for Research in Vision and Ophthalmology, American Academy of Ophthalmology, American College of Surgeons, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Kerry Assil, MD Medical Director and CEO, The Sinskey Eye Institute

Kerry Assil, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, and Contact Lens Association of Ophthalmologists

Disclosure: Nothing to disclose.

Kilbourn Gordon III, MD, FACEP Urgent Care Physician

Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society

Disclosure: Nothing to disclose.

Robert H Graham, MD Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona

Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society

Disclosure: Medscape/WebMD Salary Employment

Anisha Judge, MD Consulting Staff, Department of Ophthalmology, Kaiser Permanente at West Los Angeles Medical Center

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, and International Society of Refractive Surgery

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; RPS Ownership interest Other; Bausch & Lomb Honoraria Speaking and teaching; Merck Consulting fee Consulting; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Jack L Wilson, PhD Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee Health Science Center College of Medicine

Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association

Disclosure: Nothing to disclose.

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Herpes simplex virus dendritic ulcer stained with rose bengal.
Herpes simplex virus dendritic ulcer stained with fluorescein.
Large paracentral herpes simplex virus dendritic ulcer.
Recurrent herpes simplex virus dendritic ulcer with an adjacent stromal scar.
Healing herpes simplex virus dendritic ulcer.
Herpes simplex virus geographic ulcer.
Neurotrophic keratopathy.
Large neurotrophic ulcer.
Active immune stromal keratitis.
Inactive immune stromal keratitis.
Disciform endotheliitis with secondary stromal ulceration.
 
 
 
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