Herpes of the eye: symptoms

Herpetic eye lesions are among the most common viral diseases in humans.

From a morphological standpoint, herpes is defined as a disease characterized by a rash on the skin and mucous membranes of grouped vesicles on a hyperemic base. The causative agent of herpes is a large DNA-containing virus.

It is known that the virus parasitizes and develops in epithelial, nervous and mesodermal tissue. Depending on the localization of the infectious process, there are lesions of the herpes simplex virus of the skin, mucous membranes, central nervous system and peripheral nerve trunks, internal organs, and the organ of vision. Some of these lesions are accompanied by the development of serious general disorders and generalization of the infection, which occurs, in particular, in newborns with intrauterine infection. All this allows a number of authors to speak not only of a herpes infection, but also of a herpes disease, polymorphic in clinical manifestations and peculiar in pathogenesis. Infection with generalized localization can lead to death.

A special place in herpes disease is occupied by damage to the organ of vision, which can affect the eyelids, conjunctiva, sclera, cornea, anterior and posterior sections of the vascular tract, retina, optic nerve. The cornea is most often affected, which is associated with its low immunity. Herpes of the eye is more common in countries of the middle zone of the globe, where respiratory diseases are most common. In spring and autumn, the number of patients increases. It is possible that in these cases there is a mixed infection with the herpes simplex virus and the influenza or parainfluenza virus. It is also necessary to take into account the fact that the viral infection persists for a long time (up to 2 years), in particular in the salivary and lacrimal glands, conjunctiva.

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Herpes simplex of the eyelids

Simple herpes of the eyelids, in its clinical picture, usually does not differ from group herpetic eruptions in other areas of the skin of the face (near the wings of the nose, around the mouth opening, etc.).

The rash is usually preceded by general symptoms such as chills, headache, and fever. This is accompanied by local symptoms (burning, sometimes itching of the skin of the eyelids), followed by the appearance of grayish blisters, which are the result of the exfoliation of the integumentary epithelium of the skin due to exudative effusion. The blisters are usually located on the hyperemic base of the skin, grouped in several pieces, sometimes merging. A few days after the appearance, the contents of the blisters become cloudy, then crusts form, which disappear, leaving no scars on the skin. In case of relapse of herpes, blisters usually appear in the same place. If herpetic dermatitis occurs simultaneously with the disease of the eyeball itself, this contributes to the etiological diagnosis of the eye process.

Herpetic conjunctivitis

Herpetic conjunctivitis occurs more often in children and does not have constant, pathognomonic signs for herpes, differing in polymorphism of symptoms. The catarrhal clinical form of conjunctivitis, follicular form similar to adenoviral conjunctivitis, and membranous form are known. Mixed viral infection of the conjunctiva is not excluded, which explains the diversity of the clinical picture. The final diagnosis is established by cytological and immunofluorescent studies, after which appropriate therapy is carried out. Herpetic conjunctivitis is characterized by a sluggish course, a tendency to relapse.

Currently, the clinical picture of herpetic keratitis has been studied most thoroughly. They account for 20% of all keratitis, and in pediatric ophthalmology practice even 70%. Herpetic keratitis, unlike some other viral diseases, develops in animals (monkeys, rabbits, rats), which allows for experimental studies of this pathology. Keratitis can be primary and post-primary. Newborns usually have antibodies to the herpes simplex virus, received in the prenatal period through the placenta and after birth through mother's milk. Thus, a newborn, if he was not infected in the antenatal period or at birth, is to a certain extent protected from herpes infection by passive immunity transmitted to him by the mother. This immunity protects him from infection for 6-7 months. But after this period, all people, as a rule, become infected with the herpes simplex virus, which happens unnoticed. The infection gets to the child by airborne droplets, through kisses of adults, dishes. Incubation period is 2-12 days. Primary herpes infection in 80-90% of cases is asymptomatic, but can lead to severe diseases of the skin, mucous membranes, eyes up to viral septicemia with cyanosis, jaundice, meningoencephalitis.

Primary herpetic keratitis

Primary herpetic keratitis accounts for 3-7% of herpetic eye lesions. Since the antibody titer to the herpes simplex virus in a sick child is very low, the disease is very severe. The process begins more often in the central parts of the cornea, the trophism of which is somewhat lower than in the peripheral parts adjacent to the marginal looped vascular network and, as a result, are in better nutritional conditions. Keratitis occurs with ulceration of the corneal tissue, early and abundant vascularization, after which a pronounced opacity of the cornea remains.

At the age of 3-5 years, children develop immunity to the herpes simplex virus, and the infection becomes latent, remaining in the body for life. Later, under the influence of various factors, exacerbations of the disease occur. Such factors include any infection, most often viral (respiratory disease, flu, parainfluenza), hypothermia, intoxication, trauma. These conditions cause a decrease in the tension of antiviral immunity, and the disease recurs. It can have various clinical manifestations (herpes labialis, stomatitis, encephalitis, vulvovaginitis, cervicitis, conjunctivitis, keratitis). Such keratitis, which occurs against the background of a latent herpes infection, is called post-primary. In this case, the patient does not necessarily have suffered from primary herpetic keratitis in the past. His herpes infection could have had a different localization. But if keratitis developed after a primary herpes infection against the background of existing unstable immunity, then it already belongs to the category of post-primary keratitis.

Very rarely the process is limited to a single outbreak. Most often it recurs 5-10 times. Relapses are cyclical, occur in the same eye, in the same place or near the old lesion. Sometimes a relapse is preceded by an eye injury. Very often the next exacerbation coincides with an increase in body temperature, cough, runny nose. This should be taken into account when making a diagnosis. Relapses greatly worsen the course of keratitis and the prognosis, since after each of them the cornea remains cloudy.

When collecting anamnesis, the patient should be asked whether he had a catarrhal condition of the upper respiratory tract before the eye disease. It is necessary to establish whether the patient has frequent herpetic rashes on the skin, in the mouth, in the nasal cavity.: This fact also helps in the diagnosis of herpetic keratitis, indicating a low tension of antiviral immunity.

Before focusing on the condition of the diseased eye, it is necessary to examine the skin and mucous membranes, to find out if there are any manifestations of herpetic infection, which is often combined with herpes of the eyeball and its adnexa. Currently, two strains of herpes have been identified. The first - oral - causes a rash of herpetic elements on the face, lips, nose. The second - genital - affects the genital area, the anal area. When examining a patient, one should avoid false modesty and inquire about the condition of all suspicious areas of the skin and mucous membranes, keeping in mind that herpetic rashes are located mainly around natural openings, in those places where the mucous membrane passes into the skin.

When analyzing the condition of the diseased eye, it should be remembered that herpetic keratitis is mostly unilateral. Despite the fact that the herpetic infection is widespread throughout the body and localized, in particular, in the tissues of the healthy eyeball, as evidenced by the characteristic cytological changes in the conjunctiva of the healthy eye and a positive immunofluorescence reaction with the herpetic antigen, the pathogenic properties of the infection are realized on one side. However, sometimes keratitis is bilateral. The reason for this is unknown. A connection with a more virulent strain of the herpes simplex virus or insufficient tension of the antiviral immunity cannot be ruled out, which allows the infection to realize its pathogenic properties in the cornea of both eyes. Viral keratitis is characterized by a sharp decrease or complete absence of sensitivity of the cornea, which is caused by the neurotropic features of the herpes simplex virus.

The fact of decreased or complete absence of tissue sensitivity in herpetic keratitis can be explained on the basis of original findings in biomicroscopic examination. Examination of the cornea with direct focal illumination and an expanded illumination slit makes it possible to obtain an optical prism of the cornea; it reveals thickening of the nerve trunks covered with a myelin sheath, their bead-like appearance. Together with decreased or absent tissue sensitivity, this allows us to state neuritis or perineuritis of the trunks of the long and short ciliary nerves responsible for sensitivity and trophism of the cornea. Objective hypoesthesia of the cornea is accompanied by subjective hyperesthesia.

Post-primary herpetic keratitis

Post-primary herpetic keratitis is characterized by a small number of newly formed vessels and even their complete absence. In primary herpetic keratitis, characterized by the decay of corneal tissue, there may be abundant neovascularization. It is necessary to emphasize the sluggish course of the inflammatory process, very slow regeneration of the affected tissue. Usually, the acute onset does not correspond to the rigid background of the disease. The listed general and local signs characterizing corneal herpes allow us to make the correct diagnosis.

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Herpes of the cornea

As is known, corneal herpes can occur in various clinical variants, which largely determines the outcome of the process. A thorough examination of the affected cornea makes it possible to classify herpetic keratitis among the following, most common clinical forms. The information provided below is convenient to use, especially when working in a wide polyclinic network.

In the superficial form of keratitis, the process is localized in the epithelial layer of the cornea. Here, the epithelial action of the herpes simplex virus is mainly manifested. Infiltrates in the form of gray dots alternate with bullous elements, localizing in the places where the nerve trunks of the cornea end.

Sometimes the epithelial layer peels off during blinking movements of the eyelids and twists into a kind of thread, attaching to the eroded surface of the cornea in some area. In this case, a clinical form of a rather rare filiform keratitis develops. Corneal erosions that remain after the opening of the vesicular epithelial element heal extremely slowly and often recur. Practitioners are well aware of the clinical form of dendritic or bushy herpetic keratitis. It received its name due to a very peculiar type of erosion of the corneal epithelium, which resembles a branch of a bush or tree. This is due to the fact that infiltration in the affected cornea is located along the inflamed nerve trunks. It is here that bullous elements of the epithelium appear, very soon opening and leading to the formation of a branched erosion, since the nerve trunks of the cornea themselves branch.

Despite the fact that the dendritic form is similar in its clinical manifestations to corneal herpes of superficial localization, it also contains elements of deeper penetration of the infection. This is expressed in edema of the corneal stroma surrounding the dendritic erosion and the appearance of folding of the Descemet membrane. The classic form of deep herpetic keratitis is discoid keratitis. It develops when the herpes simplex virus penetrates the corneal stroma from the outside or hematogenously. Infiltration occupies the central optical zone of the cornea, has the shape of a disc, which is why this form is called discoid. The disc is usually sharply outlined, clearly delimited from healthy corneal tissue, and is located in its middle layers. Sometimes it is surrounded by two or three rings of infiltrated tissue. The rings are separated by light spaces. Edema of the cornea is observed over the zone of localization of the disc up to the formation of fairly significant bubbles. The endothelium of the posterior surface of the cornea undergoes the same changes.

The thickness of the cornea in the affected area increases. Sometimes the thickening is so significant that the optical section of the cornea changes its shape. The anterior edge of such a section protrudes forward, and the posterior edge significantly protrudes into the anterior chamber of the eye. The process is accompanied by the appearance of pronounced folds of Descemet's membrane. Over time, with discoid keratitis, scanty deep vascularization may appear in the cornea. The outcome of the process in terms of restoring normal visual acuity is rarely favorable.

In cases where the herpetic infiltrate of the cornea ulcerates, a rigid corneal ulcer occurs, often with scalloped edges, called a landscaping ulcer. The healing of such an ulcer is extremely slow.

Metaherpetic keratitis

The clinical picture of metaherpetic keratitis deserves special attention. Metaherpetic keratitis is a kind of transitional form of the process, which, against the background of weakened resistance of the organism and weakened immunity of the cornea, develops from any clinical manifestation of viral herpetic keratitis. Most often, the disease occurs against the background of dendritic or landcartoid keratitis. In terms of the type of lesion, the metaherpetic form resembles herpetic landcartoid keratitis, but the metaherpetic ulcer is deeper. The cornea around it is infiltrated, thickened, the epithelium against this background is edematous and bullous raised. The process is mostly accompanied by iridocyclitis.