Good Hope, Heartlands, and Solihull Eye Clinics

Herpetic keratitis related: dendritic ulcers & disciform keratitis & cytomegalovirus corneal endothelialitis

David Kinshuck


What is the cornea?

The cornea is the 'window' of your eye. It is the clear glass-like front.

close up view of cornea



What is the herpes virus?

a dendritic ulcer with many 'dendrites'

The herpes simplex virus is very common. Most people have a herpetic infection at some time of their lives. However, only in a few unlucky people does the virus affect the cornea.

No one knows why some people develop corneal infections not others. It has nothing to do with sex ...that is a different type of herpes virus.


What are dendritic ulcers?

a dendritic corneal ulcer

The virus causes a special type of corneal ulcer, called 'dendritic' (after the latin term that means 'many fingered').


A dendritic ulcer has many 'fingers', like the branch of a tree. It can be seen with the slit lamp microscope used to examine your eye. Fluorescent yellow drops are used to show the ulcer up more easily.




dendritic ulcer, diagram


dendritic ulcer: as seen by your doctor

dendritic ulcer, diagram, side view

dendritic ulcer: side view









What do you feel?

dendritic ulcer is painful: diagram

a dendritic ulcer (like a 'tree'); reduced corneal sensation

As the cornea has many nerves it feels pain easily. Dendritic corneal ulcers are painful; your eye feels as though something is scratching it. Sunlight and bright lights feel painful also. As the ulcer is like 'paint on a window' your sight may be blurred.

In this condition the corneal nerves are damaged, and sensation is reduced. This is a test a doctor can carry out as part of the examination. CO 17






The treatment

acyclovir eye cream

treatment: Aciclovir or increasingly Ganciclovir cream

The treatment is Virgan/gangcylovir 5 times a day till healed, then one drop 3 times a day for 1 week. With prompt treatment you get a 100% recovery.

Sometimes you get a faint scar, although this is more likely without treatment.

Bring the treatment to clinic each visit, with all your other drops and list of tablets you use. It is very safe. Use about 2cm length of cream 5 times a day at the beginning, but later in the episode as your eye heals you need less (5-10mm), although you may still need it 5 times a day. Longer treatment is needed if you are immunosuppressed.

Just at present in the UK Aciclovir is not currently available, and Ganciclovir cream is used instead. Indeed,  Ganciclovir is active against CMV, which may be an alternative cause of the 'disciform' or stromal keratitis described on this page.

A typical dendritic ulcer: no need to review patient.
If the symptoms have lasted more than more than 1 week,  and in larger, peripheral ulcers, a PCR can be helpful to identify the virus.

If the ulcer persists, there may be a neurotrophic problem. Resistance rare
but can be treated with Acyiclovir 800mg 5 times a day and Foscarnet, but these are VERY rarely needed.


Recurrences: can you treat yourself?

Dendritic ulcers (and herpetic eye disease as below) may recur. It is certainly helpful to keep a tube of unopened ointment with you, especially on holiday. If you do develop another episode it is quite safe to start treatment. (Aciclovir is safe even if you are mistaken and there is no infection.)

Use the Aciclovir, following typical instructions as above. Most doctors advise you attend an Eye Casualty, such as that in Birmingham and Midland Eye Centre on the City Hospital site (Dudley Road), that day or the next. Treatment is not so urgent as to need to attend late in the evening or the middle of the night.

Like any infection, stress, overwork, or lack of sleep can trigger a recurrence. Dendritic ulcers can be triggered by sunlight. Dark glasses may help prevent a recurrence, and they certainly help during an attack. If you develop frequent episodes, ask your doctor if long term Aciclovir cream or tablets may be helpful as prevention.


Recurrences can be prevented

There is now conclusive evidence that attacks can be prevented with the use of Aciclovir, see here (2003). Treatment may be needed for 2-3 years.

  • this evidence indicates using Aciclovir tablets 400mg twice daily will halve the number of attacks
  • if you have frequent attacks, you should ask your doctor to consider this treatment; it is usually very safe
  • what are frequent attacks: probably more than one a year
  • if you have one attack a year normally you will probably still benefit
  • the more severe your attacks, the more you will benefit; if the condition affects the centre of your cornea, prevention is more important
  • Ganciclovir cream may prevent recurrences, but is not as effective as tablets. Use if patient unwell (other medical problems) instead of tablets
  • Aciclovir is generally safe for long term use but rarely causes crystals in the kidneys. As a precaution it is important to drink plenty of fluids, and it is not ideal long-term if kidney function is reduced.
  • Vitamin D has helped some patients
  • Many patients notice a recurrence without continuing a steroid drop. But often only a low does of steroid, such as FML once a day or even less often, will be effective.
  • Use prophylaxis in cataract and corneal graft surgery (Ganciclovir with the post-op steroids in cataract surgery).
  • A flu vaccine can cause reactivation (prophylaxis should prevent this).


  Corneal endothelialitis (probably cytomegalovirus cytomegalovirus), previously termed, 'Stromal' or 'disciform' keratitis

diagram of stromal keratitis

Corneal endothelialitis (disciform keratitis) is a deeper infection the cornea
(deeper than the dendritic ulcer above)

If the infection is in the substance of the cornea the condition is called corneal endothelialitis or 'stromal keratitis' or 'disciform keratitis' or 'herpetic' keratitis'.
Treatment: Ganciclovir 5 times a day till healed, then one drop 3 times a day for 1 week.

This condition is now thought to be due to either the cytomegalovirus or the herpes simplex virus, but the treatment is the same.

Early routine cases usually do not need steroid drops, but sometimes low dose steroid drops may be needed (such as predsol), but only under close ophthalmological supervision.
If you need steroid drops for one episode you may also need them for future episodes.

Stromal keratitis attacks may recur frequently. If they do, preventative treatment may work. Aciclovir tablets 400mg once or twice a day halves the number of episodes, but may be needed for a year or two. If Aciclovir tablets cause side effects, use Ganciclovir 1-2 times a day long term.

Disciform keratitis may be due to cmv, and is now termed corneal endothelialitis  BJO 14  (cytomegalovirus corneal endothelialitis). Ganciclovir is the best treatment.

  • PCR test
  • treatment  BJO 17 
  • those +ve for cmv
    • coin shaped lesion, corneal oedema
    • 10% ..linear

a corneal scar..similar to an old herpes simplex scar

In disciform keratitis the central cornea is cloudy/opaque.
Also, a semi-opaque scar may remain after the infection itself has cleared.


Herpetic keratouveitis

Sometimes in addition to the corneal infection above, there is inflammation in the front chamber of the eye (a type of iritis). This condition is termed herpetic keratouveitis. Treatment is antiviral tablets Aciclovir 400mg 5 times a day initially. Steroid drops may be needed in addition, but in a straightforward case these may not be needed. Wilki


Herpetic uveitis

Sometimes there is no obvious corneal infection as above, but there is inflammation in the front chamber of the eye (a type of iritis). This condition is termed herpetic uveitis. Treatment is antiviral tablets Aciclovir 400mg 5 times a day initially. Steroid drops may be needed in addition, but in a straightforward case these may not be needed. Drops may be needed to dilate the pupil, such as cyclopentolate 1% twice a day.  Wilki   AAO 09


Herpetic uveitis and secondary glaucoma

Sometimes the herpetic uveitis causes glaucoma. That is, the inflammation blocks the drainage of fluid in the eye .This condition is termed herpetic uveitis. Treatment is antiviral tablets Aciclovir 400mg 5 times a day initially, probably steroid drops, but also drops to lower the eye pressure. Drops may be needed to dilate the pupil, such as cyclopentolate 1% twice a day. See, see,  


For Professionals: steroid drops in herpetic keratitis etc

Some patients with delayed healing dendritic ulcers may need a different antiviral, but resistance is very rare and this is not usually necessary.
More often, steroid drops are needed. Stromal keratitis will need steroid drops at the onset.

  • always test for sensation
  • if a person needs steroid drops to heal their ulcer, then if they get further episodes, steroids will be needed again
  • it is best to taper the steroids after the attack, continuing them well after the ulcer has healed. Often drops will be needed for 6-12 months
  • treatment starts will full strength drops (prednisolone 0.5%), but then reduced each month, to prednisolone 0.1% (or 0.5% every other day if not available), then ideally to 0.01%, over this 6-12 month period
  • Antivirals are needed in addition to the steroid until the 0.01% dilution is reached.
  • some infections become resistant to Aciclovir...
  • if any uveitis Aciclovir 4-800mg five times day, no steroid if  possible, not safe for 10 days
  • some patients need on-going treatment with low dose topical steroids, such as prednisolone 0.05 or 0.1%. If these are not available, may be alternate day treatment of 0.5% may help.
  • 20% of apparent HSV keratitis is HZV
  • review
  • generally dendritic ulcers (epithelial disease only) do not need treatment with steroids
  • amniotic membrane AJO17