Diagnosis and management of herpes simplex stromal keratitis

The diagnosis and optimal management of herpes simplex stromal keratitis can be problematic. Clinical features that should be evaluated include the status of the epithelium and the location and type of stromal inflammation. Two principal forms are recognized: nonnecrotizing, or disciform, keratitis and necrotizing keratitis. Both types may coexist and are sometimes accompanied by iridocyclitis and secondary ocular hypertension. Laboratory evaluation is not usually performed, although, lacking a prior history of herpes simplex epithelial keratitis, testing should be considered to seek another cause of stromal inflammation. A topical steroid is generally contraindicated in the presence of herpes simplex epithelial keratitis and has been implicated in prolonging the course of herpetic eye disease. However, judicious topical steroid therapy can be beneficial when used with protective antiviral cover for herpes simplex stromal keratitis without epithelial keratitis. Systemic antiviral therapy may prove to be a valuable adjunctive treatment, and further clinical trials are anticipated.