Herpes of the eye: symptoms

Herpetic eye lesions are among the most common viral diseases of a person.

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

It is known that the virus parasitizes and develops in the epithelial, neural and mesodermal tissues. Depending on the localization of the infectious process, the disease is distinguished by 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 infection, which occurs, in particular, in newborns with intrauterine infection. All this allows a number of authors to speak not only of herpetic infection, but also of a herpetic disease, polymorphic in clinical manifestations and peculiar in pathogenesis. Infection with generalized localization can lead to death.

A special place in herpetic disease is the damage to the organ of vision, in which eyelids, conjunctiva, sclera, cornea, anterior and posterior parts of the vascular tract, retina, optic nerve can suffer. The most commonly affected cornea, which is due to its low immunity. Herpes of the eye is more common in the countries of the central strip of the globe, where respiratory diseases are most frequent. In the spring and autumn the number of patients increases. It is not excluded that in these cases there is a mixed infection with the herpes simplex virus and the influenza virus or parainfluenza. It is also necessary to take into account the fact of long (up to 2 years) preservation of the viral infection, in particular in the salivary and lacrimal glands, conjunctiva.

[1], [2], [3]

Herpes simplex

Herpes simplex in the clinical picture usually does not differ from the group herpetic eruptions in other parts of the facial skin (near the wings of the nose, around the mouth opening, etc.).

The rash is usually preceded by common phenomena in the form of chills, headaches, fever. This is accompanied by local symptoms (burning, sometimes itchy skin of the eyelids), followed by the appearance of bubbles of grayish color, which are the result of detachment of the integumentary epithelium of the skin due to exudative effusion. Vesicles are usually found on the hyperemic skin, grouped into several pieces, sometimes merging. A few days after the onset, the contents of the vesicles grow turbid, then crusts form which disappear, leaving no scars on the skin. When the herpes recur, vesicles usually occur in the same place. If herpetic dermatitis occurs simultaneously with the disease of the eyeball itself, it contributes to the etiologic diagnosis of the ocular process.

Herpetic conjunctivitis

Herpetic conjunctivitis often occurs in children and has no permanent, pathognomonic for herpes symptoms, differing in the polymorphism of the symptomatology. Known catarrial clinical form of conjunctivitis, follicular form, similar to adenoviral conjunctivitis, and filmy. 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 immunofluorescence studies, after which appropriate therapy is carried out. Herpetic conjunctivitis is characterized by a sluggish course, a tendency to relapse.

At present, the clinical picture of herpetic keratitis has been most thoroughly studied. They account for 20% of all keratitis, and in pediatric ophthalmic practice, even 70%. Herpetic keratitis, unlike some other viral diseases, develops in animals (monkeys, rabbits, rats), which allows conducting experimental studies on this pathology. Keratitis can be primary and post-primary. Newborns usually have antibodies to the herpes simplex virus obtained during the uterus through the placenta and after the birth of the baby through the mother's milk. Thus, a newborn, if he has not been infected in the antenatal period or at birth, is to some extent protected from herpes infection by the passive, transmitted to him by the mother's immunity. This immunity protects him from infection for 6-7 months. But after this period, all people are usually infected with the herpes simplex virus, which happens unnoticed. The infection gets to the child airborne, through kisses of adults, dishes. Incubation is 2-12 days. Primary herpetic 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 the phenomena of cyanosis, jaundice, meningoencephalitis.

Primary herpetic keratitis

Primary herpetic keratitis is 3-7% of herpetic lesions of the eyes. Since the sick child has a titer of antibodies to the herpes simplex virus, it is very difficult. The process begins more often in the central parts of the cornea, the trophicity of which is somewhat lower than in the peripheral regions adjacent to the marginal loopy vasculature and, as a result, in better nutrition conditions. Keratitis occurs with ulceration of the corneal tissue, early and profuse vascularization, after which a pronounced clouding of the cornea remains.

At the age of 3-5 years, children have immunity to the herpes simplex virus, and the infection passes into a latent state, remaining in the body for life. In the future, under the influence of various factors, there are exacerbations of the disease. Such factors include any infection, more often viral (respiratory disease, influenza, parainfluenza), hypothermia, intoxication, trauma. These conditions cause a decrease in the strain of antiviral immunity, and the disease recurs. It can have various clinical manifestations (herpes lips, stomatitis, encephalitis, vulvovaginitis, cervicitis, conjunctivitis, keratitis). Such keratitis, which arose on the background of a latent flow of herpetic infection, is called postprimary. At the same time, the diseased patient does not necessarily carry the initial herpetic keratitis in the past. Herpetic infection in him could have a different localization. But if keratitis has developed after the primary herpetic infection against the background of the existing unstable immunity, then it already belongs to the category of post-primary keratitis.

Very rarely the process is limited to a single flash. Most often it recurs 5-10 times. Relapses are cyclical, arise in the same eye, in the same place or next to the old hearth. Sometimes a trauma to the eye precedes the relapse. Very often, another exacerbation coincides with an increase in body temperature, a cough, a runny nose. This should be taken into account when making a diagnosis. Relapses strongly worsen the course of keratitis and prognosis ,. Since after each of them a clouding remains on the cornea.

Collecting the anamnesis, it is necessary to ask the patient the question whether he had a catarrhal condition of the upper respiratory tract before his eye. It is necessary to establish whether the patient does not have frequent herpetic eruptions on the skin, mouth, or nasal cavity. This fact also helps in the diagnosis of herpetic keratitis, indicating a low strain 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 whether there is anywhere on them manifestations of herpetic infection, which is often combined with herpes of the eyeball and its adnexa. Currently, two strains of herpes are isolated. The first - oral - causes the precipitation of herpetic elements on the face, in the area of the lips and nose. The second - genital - affects the genital area, anus of the anus. When examining a patient, one should avoid false modesty and inquire about the state of all suspicious areas of skin and mucous membranes, bearing in mind that herpetic eruptions are located mainly around natural openings, in those places where the mucous membrane passes into the skin.

Turning to the analysis of the condition of the diseased eye, it should be remembered that herpetic keratitis is mostly one-sided. Despite the fact that the herpetic infection is spread throughout the body and is localized, in particular, in the tissues of a healthy eyeball, as evidenced by the characteristic cytological changes in the conjunctiva of the healthy eye and the positive reaction of immunofluorescence with herpetic antigen, the pathogenic properties of the infection occur on one side. However, sometimes keratitis is bilateral. Than it is caused, it is not known. It is possible that there is a connection with a more virulent strain of herpes simplex virus or an insufficient strain of antiviral immunity, which allows the infection to realize its pathogenic properties in the cornea of both eyes. Viral keratitis is characterized by a sharp decrease or total absence of sensitivity of the cornea, which is caused by neurotropic features of the herpes simplex virus.

The fact of a decrease or total absence of tissue sensitivity in herpetic keratitis can be explained on the basis of original findings in a biomicroscopic study. Inspection of the cornea under direct focal light and an enlarged illuminating gap makes it possible to obtain an optical prism of the cornea; in it the thickening of nerve trunks covered with myelin sheath, their clear-cut appearance are revealed. Together with a decrease or lack of sensitivity of the tissue, this allows us to establish neuritis or perineuritis of the trunks of long and short ciliary nerves, which are sensitive and trophic in the cornea. Objective hyposthenia of the cornea is accompanied by subjective hyperesthesia.

After the primary herpetic keratitis

After the primary herpetic keratitis differs a small number of newly formed vessels and even their complete absence. At the primary herpetic keratitis, characterized by the disintegration of the corneal tissue, there can be abundant neovascularization. It should be emphasized the lingering course of the inflammatory process, a very slow regeneration of the affected tissue. Usually the acute onset does not correspond to the rigid background of the course of the disease. The listed common and local signs characterizing the corneal herpes allow you to put the correct diagnosis.

[4], [5], [6], [7], [8], [9], [10]

Herpes of the cornea

As is known, the corneal herpes can occur in various clinical variants, on which the outcome of the process largely depends. Thorough examination of the affected cornea enables the herpetic keratitis to be attributed to the following, the most common clinical forms. The following information is convenient to use, especially when working in a wide polyclinic network.

With the surface form of keratitis, the process is localized in the epithelial layer of the cornea. Here, the epitheliopathic effect of the herpes simplex virus is mainly manifested. Infiltrates in the form of gray dots alternate with bullous elements, localizing at the end of the nerve trunks of the cornea.

Sometimes the epithelial layer exfoliates during the blinking movements of the eyelids and twists into a kind of thread, at some point attached to the erosive surface of the cornea. At the same time, the clinical form of a rather rare filamentous filiform keratitis develops. Erosions of the cornea, which remain after the opening of the vesicle epithelial element, heal extremely slowly and often recur. Practical doctors are well aware of the clinical form of dendritic or bush-like herpetic keratitis. He received the name because of a very peculiar kind of erosion of the epithelium of the cornea, 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 the bullous elements of the epithelium appear, very soon opening and leading to the formation of erosion of the branchy species, as the nerve trunks of the cornea themselves branch.

Despite the fact that the tree form in its clinical manifestations is close to the herpes simplex of superficial localization, it carries elements of a deeper introduction of the infection. This is expressed in the edema of the stroma of the cornea surrounding the tree-like erosion, and the appearance of folding Descemet's shell. The classical form of deep herpetic keratitis is discoid keratitis. It develops when the herpes simplex virus is introduced into the corneal stroma from the outside or by the hematogenous way. Infiltration occupies the central optical zone of the cornea, it has the shape of a disk, in connection with which the given form was called discoid. The disk is usually sharply outlined, clearly delineated from healthy corneal tissue, located and its middle layers. Sometimes it is surrounded by two or three rings of infiltrated tissue. The rings are separated by light intervals. There is edema of the cornea over the zone of disc localization up to the formation of quite significant blisters. The endothelium of the posterior surface of the cornea also undergoes the same changes.

The thickness of the cornea in the affected area is increased. Sometimes the thickening is so significant that the optical section of the cornea changes its shape. The anterior edge of this cut extends anteriorly, and the posterior one extends considerably into the anterior chamber of the eye. The process is accompanied by the appearance of pronounced folds of Descemet's shell. Over time, discoid keratitis in the cornea may result in scant deep vascularization. The outcome of the process in terms of restoring normal visual acuity is rarely favorable.

In those cases where the herpetic infiltrate of the cornea ulcerates, corneal ulcers of rigid flow occur, often with scalloped edges, called land-card-shaped. The healing of such an ulcer is extremely slow.

Metaperpetic keratitis

Particular attention should be paid to the clinical picture of metaherpetic keratitis. Metaperpetic keratitis is a kind of transitional form of the process that, against the background of a 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 a background of dendritic or land-like keratitis. By the form of the lesion, the metaherpetic form resembles the herpetic landscape-like keratitis, but the metaperpetic ulcer is deeper. The cornea around it is infiltrated, thickened, the epithelium on this background is swollen and bullous elevated. The process is mostly accompanied by iridocyclitis.