Herpetic keratoconjunctivitis and keratitis in children

Primary herpetic keratoconjunctivitis develops in the first 5 years of a child's life after primary infection with the herpes simplex virus. The disease is often unilateral, with a long and sluggish course, prone to relapses. It manifests itself as catarrhal or follicular conjunctivitis, less often - vesicular-ulcerative. The discharge is insignificant, mucous. Recurrent rashes of herpetic vesicles with subsequent formation of erosions or ulcers on the conjunctiva and edge of the eyelid, covered with delicate films, with regression without scarring are characteristic. Severe systemic manifestations of herpes infection are possible, for example, encephalitis.

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Herpetic keratitis

The development of the clinical picture of the disease is preceded by hypothermia, feverish conditions; damage to the mucous membrane and skin of the eyelids is not typical; as a rule, one eye is affected. There is a decrease in corneal sensitivity, slow regeneration of foci, a weak tendency to new vessel formation, and a tendency to relapse.

Herpetic epithelial keratitis (the most common type of ophthalmic herpes - 36.3%): dendritic (vesicular, stellate, punctate), dendritic with stromal damage, map-like. The earliest signs of viral damage to the corneal epithelium are punctate epithelial opacities or small vesicles. Merging, the bubbles and infiltrates form a unique figure of a tree branch.

Herpetic stromal keratitis is somewhat less common, but it is considered a more severe pathology. In the absence of ulcers, it can be focal, with the localization of one or more foci in the superficial or middle layers of the corneal stroma. With stromal keratitis, an inflammatory process of the vascular tract almost always occurs with the appearance of precipitates, folds of Descemet's membrane.

Disciform keratitis is characterized by the formation of a rounded infiltrate in the middle layers of the stroma in the central zone of the cornea. In disciform herpetic keratitis, there are two signs that are important in differential diagnosis: the presence of precipitates (sometimes they are poorly visible due to corneal edema) and a rapid therapeutic effect from the use of glucocorticoids.

Herpetic corneal ulcer may be the outcome of any form of ophthalmic herpes when the necrotic process spreads deep into the corneal stroma with the formation of a tissue defect. Herpetic ulcer is classified as a severe disease, characterized by a sluggish course, decreased or absent sensitivity of the cornea, and occasional pain. When a bacterial or fungal infection is added, the ulcer rapidly progresses, deepens, and even leads to perforation of the cornea. The outcome may be the formation of a fused leukoma with a prolapsed iris or penetration of infection inside, endophthalmitis or panophthalmitis with subsequent death of the eye.

In herpetic keratouveitis, there are keratitis phenomena (with or without ulceration), but the signs of vascular tract damage predominate. The presence of infiltrates in various layers of the corneal stroma is characteristic. If ulceration occurs, it affects the most superficial layers of the cornea; deep folds of Descemet's membrane, precipitates, exudate in the anterior chamber, newly formed vessels in the iris, posterior synechiae are noted. Bullous keratoiridocyclitis often develops with the appearance of blisters and erosions in the epithelial cover, an increase in intraocular pressure in the acute period of the disease.

Treatment of herpetic keratoconjunctivitis and keratitis

• Antiherpetic drugs (acyclovir in the form of eye ointment 5 times in the first days and 3-4 times thereafter).
• Interferons (ophthalmoferon) or interferonogens (aminobenzoic acid) 6-8 times a day (a combination of local application of acyclovir and interferons is more effective).
• Antiallergic drugs (ketotifen, olopatadine or cromoglycic acid) 2 times a day and anti-inflammatory drugs (diclofenac, indomethacin) 2 times a day locally.

For herpetic keratitis additionally:

• mydriatics (atropine);
• corneal regeneration stimulants (taurine, dexpanthenol 2 times a day);
• tear substitutes (hypromellose + dextran 3-4 times a day, sodium hyaluronate 2 times a day).

To prevent secondary bacterial infection - picloxidine or fusidic acid 2-3 times a day.

In case of severe corneal edema and ocular hypertension, the following is used:

• betaxolol (betoptic), eye drops 2 times a day;
• brinzolamide (azopt), eye drops 2 times a day.

Local application of glucocorticoids is necessary for stromal keratitis and is contraindicated in keratitis with corneal ulceration. It is possible to use them after corneal epithelialization to accelerate the resorption of infiltration and the formation of more delicate corneal opacities. It is safer to start instillations with low concentrations of dexamethasone (0.01-0.05%), which are prepared ex tempore, or to add the drug during parabulbar injections.

Depending on the severity and acuteness of the process, systemic antiviral drugs (acyclovir, valacyclovir) in tablets and for intravenous administration, systemic antihistamines are also used.