Signs and Symptoms
virus (HSV) blepharitis is encountered primarily in children, although
adults may also manifest this disorder. Presenting symptoms include
variable pain and tenderness upon palpation, as well as increased
lacrimation in severe cases. If the conjunctiva is involved, tarsal
follicles may be observed along with bulbar injection and chemosis.
A swollen pre-auricular node on the involved side is common.
involving the lid may present in one of two forms. The classic appearance
involves an accumulation of small vesicles or pustules along the
lid margin and/or periocular skin. These lesions typically have an
inflamed, erythematous base. Within the first week of infection,
the vesicles may ulcerate or harden into crusts, although they will
ultimately resolve without scarring.
herpes simplex blepharitis
A second "erosive-ulcerative" form
of HSV blepharitis has also been described.1 This presentation
is characterized by erosions of the lid at the gray line or ulcers
along the lid margin, or a combination of both. The lid typically
displays generalized swelling and redness associated with these lesions.
The lesions usually number no more than three and, like the classic
variety, they generally resolve without scar formation.
is the most common virus found in humans. A member of the Herpetoviridae
family, HSV is a double-stranded DNA virus that replicates within
cell nuclei. As it leaves the host cell, it becomes encapsulated
and can lie dormant for extended periods of time. Several trigger
factors, including fever, trauma, emotional stress, menstruation,
exogenous immunosuppressive agents, and overexposure to UV radiation
can activate the virus. Transmission typically occurs by direct contact
with open epithelial lesions or contaminated bodily secretions. Rarely,
contaminated materials, such as towels or tissues spread the virus.
infections occur most often in children between the ages of six months
and five years, and almost invariably present as blepharitis or blepharoconjunctivitis.
In recurrent attacks, the virus usually reappears as a dendritic
keratitis. Several reports of recurrent HSV blepharitis have been
reported in the literature, however.2,3
There is no
specific treatment for HSV blepharitis, and most often the course
of the disease is self-limiting within two to three weeks.4 The
use of warm saline compresses with a topical drying agent (e.g.,
70% alcohol or aluminum sulfate [Domeboro, Bayer] solution) is usually
sufficient to palliate the patient. If the lesions are extensive,
concomitant use of topical antibiotic ointment is considered prudent
to prevent a secondary bacterial infection. The use of topical or
oral antiviral agents has not been proven to enhance the recovery
of patients with HSV blepharitis, although the use of antivirals
is still advocated by some practitioners for more severe cases. Topical
trifluridine 1% (Viroptic, Monarch) is absolutely indicated, however,
in cases presenting with corneal involvement. The use of topical
steroids on HSV lid lesions may be un-wise, particularly if there
is other ocular involvement. Although corticosteroids may be used
without fear in cases of herpes zoster (HZO) blepharitis, their use
in cases of HSV infection may predispose the patient to the eruption
of a dendritic keratitis.
herpes simplex blepharitis.
- The differential
diagnosis of HSV blepharitis should always include HZO. Keep in mind,
however, that HZO typically affects elderly patients over the age
of 70. Younger patients who present with HZO are often immunocompromised
secondary to disorders such as AIDS or lymphoma. HSV blepharitis
is usually encountered in children, but can occur at any age.
- Although herpes
simplex is known as a sexually transmitted disease, the vast
majority of ocular herpes infections are not contracted via sexual
This is important to recognize when considering pediatric cases
of HSV blepharitis.
- While the
acute management of HSV blepharitis does not seem to require
or benefit greatly from oral antiviral agents, the Herpetic Eye
showed that the recurrence of herpes simplex virus eye disease
is decreased when long-term acyclovir is used.5 Thus, patients
who experience two or more recurrences of HSV blepharitis should
be offered the option of prophylactic therapy consisting of oral
acyclovir 400mg bid.
- Egerer I, Stary A. Erosive-ulcerative herpes simplex blepharitis.
Arch Ophthalmol 1980; 98(10):1760-3.
- Besada E. Clinical diagnosis
of recurrent herpes simplex blepharitis in an adult: A case report.
J Am Optom Assoc 1994;65(4):235-8.
- Kabat AG, Espejo A, Canavan K,
et al. Recurrent herpes simplex blepharoconjunctivitis following
HSV keratitis in an adult. Optom
Vis Sci 1998; 75(12s):120.
- Lee SY, Laibson PR. Medical management
of herpes simplex ocular infections. Int Ophthalmol Clin 1996;36(2):85-97.
- The Herpetic Eye Disease Study Group. Acyclovir for the prevention
of recurrent herpes simplex virus eye disease. N Engl J Med 1998;
reports in this section