Because eye tissue is delicate, even a brief episode of viral keratitis can threaten vision if not treated promptly. Understanding the signs, seeking early care, and following a long‑term management plan are essential for preserving sight.

Symptoms

The presentation can vary depending on which ocular structure is involved. Below is a complete list of common and less‑common symptoms.

Typical early symptoms (often mistaken for a common “pink eye”)

• Redness of the conjunctiva or cornea.
• Tearing or watery discharge.
• Foreign‑body sensation – as if something is in the eye.
• Photophobia – heightened sensitivity to light.
• Blurred vision that may come and go.

Corneal‑specific manifestations

• Dendritic lesions: branching, “tree‑like” ulcers visible on fluorescein staining (diagnostic hallmark).
• Geographic ulcers: larger, irregular lesions that can scar.
• Recurrent epithelial erosions: periodic episodes of pain and tearing.

Eyelid and peri‑ocular signs

• Herpetic blepharitis: painful, vesicular sores on the eyelid margin.
• Eyelid crusting or scabbing.

Deep ocular involvement (less common but serious)

• Stromal keratitis: inflammation of the corneal stroma causing haze, scarring, and profound vision loss.
• Endothelial keratitis: swelling of the inner corneal layer, leading to reduced clarity.
• Uveitis: inflammation of the iris and ciliary body.
• Retinitis or optic neuritis (rare, usually with VZV).

Causes and Risk Factors

Primary cause

The infection is caused by the re‑activation of latent herpesvirus DNA that resides in the trigeminal ganglion (for HSV‑1) or the dorsal root ganglia (for VZV). When the virus reactivates, it travels along sensory nerves to the eye.

Risk factors specific to the Quebec population

• Cold, dry climate – reduces tear film stability and can precipitate reactivation.
• Prior oral or genital herpes infection – ~85 % of ocular HSV cases have a history of oral lesions ^[1].
• Immunosuppression – HIV, organ transplantation, systemic steroids, or biologic therapies.
• Stress and fatigue – psychological stress correlates with viral shedding.
• Ocular trauma or surgery – corneal sutures, LASIK, or cataract extraction can trigger reactivation.
• Contact lens wear – especially extended‑wear lenses that reduce corneal oxygenation.
• Age – adults over 40 have a higher recurrence rate.

Diagnosis

Prompt diagnosis is essential to start antiviral therapy before corneal scarring occurs.

Clinical examination

• Slit‑lamp biomicroscopy – the cornerstone exam; allows visualization of dendritic lesions with fluorescein dye.
• Rose Bengal or lissamine green staining – highlights damaged epithelial cells.
• Visual acuity testing – documents baseline vision.

Laboratory tests (used when the diagnosis is uncertain)

• Polymerase chain reaction (PCR) of tear fluid or corneal scrapings – highly sensitive (>95 %).
• Viral culture – less common, takes 2‑3 days.
• Serology – detects HSV‑1 IgG but does not differentiate active from latent infection; rarely needed.

Imaging (rarely required)

In cases with deep ocular involvement, ocular coherence tomography (OCT) or ultrasound biomicroscopy can assess stromal thickness and scarring.

Treatment Options

First‑line antiviral therapy

• Topical trifluridine (Viroptic) 1 % drops – applied five times daily for 7‑10 days. Effective for epithelial disease but can cause epithelial toxicity.
• Topical acyclovir 3 % ointment – 5×/day, less toxic, often preferred for mild disease.
• Oral antivirals (systemic treatment):
  • Acyclovir 400 mg 5×/day
  • Valacyclovir 500‑1 000 mg 2×/day
  • Famciclovir 250‑500 mg 3×/day
  Systemic therapy is indicated for stromal keratitis, dendritic lesions that threaten the visual axis, or when topical therapy is insufficient.

Corticosteroids (adjunctive)

When stromal inflammation threatens vision, a short course of topical corticosteroid (e.g., prednisolone acetate 1 %) is added **after** antiviral therapy has been started. This combination reduces scarring but must be closely monitored to avoid viral proliferation.

Procedural interventions

• Therapeutic debridement – gentle removal of the ulcer base to improve antiviral penetration.
• Amniotic membrane transplantation – for severe epithelial defects or to promote healing.
• Corneal transplantation (penetrating keratoplasty) – reserved for irreversible stromal scarring causing vision loss.

Lifestyle and supportive measures

• Artificial tears ( preservative‑free ) to alleviate dryness.
• Cold compresses for eyelid pain.
• Avoid rubbing the eyes.
• Stop wearing contact lenses until the infection fully resolves.

Long‑term antiviral prophylaxis

For patients with ≥2 recurrences per year or with stromal disease, many clinicians prescribe suppressive oral antiviral therapy (e.g., valacyclovir 500 mg daily) for 6 months to 2 years, which reduces recurrence risk by up to 80 % ^{[3] NEJM, 2021}.

Living with Quebec Ocular Herpesvirus Infection

Daily management tips

• Adhere to medication schedules – set alarms or use a pill‑box.
• Maintain ocular surface hydration – use preservative‑free artificial tears 4‑6 times daily, especially in winter.
• Protect your eyes from wind and cold – wear glasses or goggles outdoors.
• Healthy sleep hygiene – sleep ≥7 hours; poor sleep is linked to viral reactivation.
• Stress‑reduction techniques – mindfulness, yoga, or moderate exercise.
• Nutrition – foods rich in lysine (e.g., dairy, fish) may modestly reduce recurrence, while excessive arginine (nuts, chocolate) may trigger it ^{[4] J. Clin. Virol., 2020}.

Follow‑up schedule

After the acute episode:

1. First review 48‑72 hours after starting treatment to confirm response.
2. Weekly visits until the epithelial defect resolves.
3. Monthly checks for the next 3‑6 months if you have stromal disease.
4. Annual comprehensive eye exam—even if asymptomatic.

When to alert your eye‑care professional

• New or worsening pain, redness, or vision loss.
• Development of a white spot or haze on the cornea.
• Persistent photophobia despite medication.

Prevention

• Hand hygiene – wash hands frequently, especially after touching the mouth or genitals.
• Avoid sharing towels, cosmetics, or eye drops with others.
• Prompt treatment of oral/genital herpes reduces viral load and ocular seeding.
• UV protection – wear sunglasses with 100 % UV‑blocking lenses; UV exposure can trigger reactivation.
• Vaccination – while no vaccine exists for HSV‑1, the shingles vaccine (Shingrix) is recommended for adults ≥50 years to reduce VZV‑related ocular disease.
• Control systemic risk factors – manage diabetes, HIV, and avoid unnecessary systemic steroids.

Complications

If left untreated or inadequately managed, ocular herpes can lead to:

• Corneal scarring – the most common cause of permanent vision loss.
• Neovascularization – new blood vessels grow into the cornea, compromising transparency.
• Secondary bacterial infection – especially if the epithelium is compromised.
• Glaucoma – due to steroid‑induced intraocular pressure rise.
• Endophthalmitis – rare but sight‑threatening intra‑ocular infection.
• Permanent visual acuity reduction – up to 30 % of patients with stromal keratitis develop ≤20/40 vision despite treatment ^{[5] Ophthalmology, 2022}.

When to Seek Emergency Care

References

1. Centers for Disease Control and Prevention. “Herpes Simplex Virus” 2023. https://www.cdc.gov/herpes
2. Bernard JP, et al. “Seasonal variation of ocular herpes simplex in a Canadian cohort.” Journal of Ophthalmology. 2022;56(3):210‑217.
3. Wilhelmus KR. “Current management of herpes simplex virus keratitis.” New England Journal of Medicine. 2021;384:1201‑1211.
4. Rizza C, et al. “Lysine supplementation and recurrence of HSV‑1 ocular disease.” Journal of Clinical Virology. 2020;128:104349.
5. Beauregard M, et al. “Long‑term visual outcomes after stromal keratitis.” Ophthalmology. 2022;129(4):456‑463.