HERPES SIMPLEX BLEPHARITIS

Signs and Symptoms

Herpes simplex 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.

Pustular herpes simplex blepharitis

HSV infections 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.

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.

Pathophysiology

Herpes simplex 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.

Primary ocular 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

Management

Erosive/ulcerative herpes simplex blepharitis.

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.

Clinical Pearls

• 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 contact. 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 Disease Study 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.

Other reports in this section

• Floppy Eyelid Syndrome
• Herpes Simplex Blepharitis
• Dacryocystitis
• Dermatochalasis & Blepharochalasis
• Xanthelasma