["Herpetic keratitis". Various expressions require different therapeutic approaches]. / "Herpeskeratitis". Unterschiedliche Ausprägungsformen erfordern unterschiedliche Therapieansätze.

Herpes simplex virus (HSV) is a common cause of keratitis. "Herpetic keratitis" is a chameleon, which is well treatable today if the various types of clinical expression of this disease are known to the ophthalmologist and treatment is adjusted accordingly. Types of expression include 1. epithelial keratitis (dendritica/geographica), 2. stromal keratitis (necrotizing vs. non-necrotizing = "interstitial keratitis"), 3. endotheliitis (=disciform keratitis), 4. neurotrophic keratopathy (=so-called metaherpetic keratitis) and 5. (vascularized) corneal scars. A concomitant ocular hypertension should be treated predominantly non-surgically (no prostaglandin analogues). Topical artificial tears (if necessary with acyclovir ointment at night) in the quiet interval are recommended to limit the tendency towards recurrences. After keratoplasty and in cases of severe recurrences of herpetic keratitis, systemic acyclovir application (2×400 mg/day) for at least 1 year is indispensable! Overall, HSV has lost its "terror" today, even after keratoplasty, given adequate management.

Herpes simplex virus stromal keratitis is not titer-dependent and does not correlate with neurovirulence.

We developed a murine model of ocular herpes simplex virus (HSV) disease which is particularly suited for testing stromal keratitis because most animals show some evidence of infection. Using this model, we characterized the ocular disease patterns caused by ten recent low-passage clinical isolates of HSV-1, as well as those caused by the established laboratory strains HSV-1 KOS and HSV-2 333. Viral strains were evaluated for their ability to cause stromal keratitis, blepharitis, vascularization of the cornea, and mortality. The model was not useful for scoring epithelial keratitis. The ocular disease caused by the recent isolates ranged from very mild disease to severe stromal keratitis. Some of the recent isolates caused disease as severe as the two laboratory strains. A comparison of the virulence characteristics expressed by various HSV strains indicated that the ability to cause stromal disease was correlated with vascularization of the cornea (correlation coefficient = 0.797, P less than 0.001) and was not correlated with the neurovirulence of the strains (correlation coefficient 0.045, P greater than 0.05). The severity of stromal keratitis was not dependent on the amount of inoculum over the range tested and a strain causing severe stromal keratitis caused severe ocular disease even when mixed with a nonstromal strain at ratios of 10:1, 100:1, and 1000:1.

[Pathological analysis of 100 cases of severe deep stromal herpetic keratitis].

Based on the pathological observation of 100 cases of severe deep stromal herpetic keratitis, the author suggested the classification of the disease, according to the nature and progression of the chronic inflammation, into 2 categories of the acute active stage (40%) and chronic progressive stage (60%), which were in agreement with the clinical manifestations and also satisfactorily explained the pathogenetic basis of the clinical types. Inflammatory granuloma appeared in 21% of the cases, indicating that the corneal lesions were still in progress.

Ocular herpes simplex infection: pathogenesis and current therapy.

Ocular herpes simplex disease has a variable pattern of manifestations and recurrences as a result of the site and extent of the infection, the host immunologic events, the trophic damage within ocular tissues, and the toxic effects of antiviral medications. Laboratory research has established a clinical model and a working hypothesis about the complex pathophysiologic features of the disease and the interaction of the virus with its host tissue. Recent studies have further defined the viral genome and its role in virulence and pathogenicity. Antiviral therapy is effective in some but not all aspects of the ocular infection. A proposed clinical classification of ocular herpes simplex is based on the manifestations associated with viral disease and those associated with the host response and the subsequent structural damage. A plan for medical and surgical management of ocular herpes simplex, based on current knowledge of the disease process, relates to the integrity of the epithelium and the presence of active viral disease.

Histopathology of herpes simplex virus keratouveitis.

Twenty-four eyes removed for complications of HSV keratitis were studied histopathologically. There were 20 men and 4 women with an average age of 61 years. Severe keratitis was seen in 14, moderate in 7, and mild in 3 eyes. Common features associated with severe keratitis were: acute perforation, granulomatous keratitis with giant cells in the stroma and Descemet's region, stromal inflammatory cells, angle-closure, severe iridocyclitis with diffuse or focal infiltration of lymphocytes and plasma cells, low-grade vitritis, choroiditis, and/or retinal periphlebitis. Specimens with moderate to mild keratitis had a similar distribution of inflammation but a lower incidence of granulomatous keratitis.

Clinical aspects of herpetic eye diseases.

Diagnosis and treatment of herpes simplex virus eye diseases has benefitted from a vast amount of clinical and experimental studies. In this short presentation reference can only be made to some fields, which may illustrate--pars pro toto--the progress achieved during the last years. Clinico-virological correlation studies have led to a better understanding and classification of different typical clinical pictures, especially those affecting the structures of the anterior chamber: endotheliitis trabeculitis, and focal serous iritis. Antiherpetic drugs have become available which do not only penetrate the cornea in sufficient amounts but can also be used systemically. This will lead to a new role of steroids in the treatment of intraocular herpetic diseases. The combination of high-titer human interferon eye drops with a basic therapy of topical antiviral agents has considerably improved therapeutic results in dendritic keratitis.

Analysis of glycoproteins expressed by isolates of herpes simplex virus causing different forms of keratitis in man.

An in vitro analysis of glycoprotein produced by nine human ocular isolates of HSV-1 is reported. The source of the isolates was; three patients with recurrent dendritic keratitis, three with chronic stromal disease and three with primary keratoconjunctivitis. Virus strains were labelled with the radioactive precursors (35S) methionine and (14C) glucosamine. Radiolabelled viral glycoproteins were subsequently analysed by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE), followed by autoradiography. Viral glycoproteins were further characterised by immuno-precipitation with polyclonal and monoclonal antibodies to HSV. The stromal isolates excrete larger amounts of 'soluble' precursor glycoprotein D than those in the other two disease categories. It is possible that the immune response to glycoprotein D is in part responsible for the severity of stromal disease.

Herpes simplex ocular disease.

The present epidemic of genital herpes has led to broad concern among both physicians and lay persons. For those who specialize in cornea and external disease, this new awareness provides a much needed opportunity to discuss ocular herpetic disease. Through ongoing medical education, great strides are being made toward early diagnosis and appropriate therapy. The primary care physician occupies a pivotal position in these efforts.

Summary code for ocular herpes simplex.

A code for herpetic eye disease is presented. This simplifies the management of individual patients, and the up-to-date code summary of each case is easily maintained thus facilitating assessment of interrelating factors. It is suggested that the pattern of herpetic eye disease may have prognostic and epidemiological significance. This system has simplified retrieval of such data.