QuizWise 1

1. Which of the following is false about Herpes simplex – 

1. Herpes keratitis in infants is caused mainly by type II herpes simplex
2. Ocular disease is most common manifestation of primary type I herpes simplex 
3. Ocular recurrence is usually caused by viral reactivation within the trigeminal ganglia 
4. Ocular recurrence is less common than either genital or oral recurrence

2. Characteristic feature of herpes simplex keratitis is – 

1. Presence of pus in the anterior chamber 
2. No tendency to recurrence
3. Corneal hypoesthesia
4. All of the above 

3. Which of the following is false about acyclovir – 

1. Topical acyclovir is less effective than oral acyclovir in the treatment of herpes simplex epithelial keratitis
2. Valacyclovir is the prodrug of acyclovir
3. The dosing frequency is less with valacyclovir than acyclovir
4. Oral acyclovir given daily can reduce the recurrence of herpes simplex epithelial keratitis

4. Acyclovir is preferred treatment for : 

1. Patient physically unable to use gel or drops (i.e., patients with intention tremor or arthritis). 
2. Contact lens wearers.
3. Pediatric patients’ refractory to topical antiviral.
4. Patients that require lengthy treatment antiviral agents (greater than 21 days).

5. In the treatment of herpes simplex stromal disease, Herpetic Eye Disease Studies (HEDS) show that:

1. topical steroid reduces the duration of the disease
2. patients on topical steroid has better visual outcome at six months review than the non-steroid treated group
3. topical steroid increases the likelihood of epithelial disease
4. oral acyclovir has added benefit in patients treated with topical steroid and trifluridine

QuizWise 1 responses

1. Answer – b : Ocular disease is most common manifestation of primary type I herpes simplex. 

Type II herpes is associated with genital herpes, infants passing through the infected birth canal can acquire ocular disease. Oral disease is more common than ocular herpes in case of primary type I herpes simplex. Human is only natural reservoir of herpes simplex. Genital and oral recurrence are commoner than ocular recurrence in herpes simplex.

Reference – Whitley RJ, Roizman B. Herpes simplex virus infections. The lancet. 2001 May 12;357(9267):1513-8. https://doi.org/10.1016/S0140-6736(00)04638-9

2. Answer – c : Corneal hypoesthesia

Visually significant complications associated with HSV keratitis, such as lipid keratopathy, corneal thinning, and neurotrophic cornea, arise from the complex interplay between viral activity and the host immune response. Confocal microscopy studies have shown that corneal dendritic cells continually evolve in density, distribution, and morphology during active herpetic endothelitis. Corneal nerve degeneration often results in significantly reduced corneal sensation. 

Reference – Valerio GS, Lin CC. Ocular manifestations of herpes simplex virus. Current Opinion in Ophthalmology. 2019 Nov 1;30(6):525-31.doi: 10.1097/ICU.0000000000000618.

3. Answer – a : Topical acyclovir is more effective than oral acyclovir in the treatment of herpes simplex epithelial keratitis

Both topical and systemic acyclovir are equally effective in the treatment of herpes simplex epithelial keratitis. Oral acyclovir reduces the ocular complication of herpes zoster ophthalmicus but does not reduce the incidence and severity of post herpetic neuralgia. 

Reference – White ML, Chodosh J. Herpes simplex virus keratitis: a treatment guideline. Hoskins Centers Compendium of Evidence-Based Eye Care. 2014 Jun. https://pdfs.semanticscholar.org/31e6/52d3851463d67a59e881e1ac8988495e212e.pdf

4. Answer – c : Contact lens wear

Trifluridine treatment is limited to 21 days, Trifluridine approved for children age 6 and older. Ganciclovir is warned against contact lens use for treatment of active herpes keratitis due to the potential link between herpes keratitis recurrence and contact lens use.

Reference – Chou TY, Hong BY. Ganciclovir ophthalmic gel 0.15% for the treatment of acute herpetic keratitis: background, effectiveness, tolerability, safety, and future applications. Therapeutics and clinical risk management. 2014;10:665. doi: 10.2147/TCRM.S58242

White ML, Chodosh J. Herpes simplex virus keratitis: a treatment guideline. Hoskins Centers Compendium of Evidence-Based Eye Care. 2014 Jun. https://pdfs.semanticscholar.org/31e6/52d3851463d67a59e881e1ac8988495e212e.pdf

5. Answer – a : Topical steroid reduces the duration of the disease

HEDS shows that topical steroids reduce the severity and the duration of herpes simplex stromal disease. However, there is no  significant difference in visual outcome between those treated with steroids and those treated with placebo. There is no increase in epithelial disease during topical steroid treatment. The study did not look into necrotising stromal keratitis. Oral acyclovir does not appear to have added benefit in those patients treated with topical steroids and trifluridine during primary treatment, however it has shown to prevent recurrences. 

1. Which of the following is false about Herpes simplex – 

1. Herpes keratitis in infants is caused mainly by type II herpes simplex
2. Ocular disease is most common manifestation of primary type I herpes simplex 
3. Ocular recurrence is usually caused by viral reactivation within the trigeminal ganglia 
4. Ocular recurrence is less common than either genital or oral recurrence

2. Characteristic feature of herpes simplex keratitis is – 

1. Presence of pus in the anterior chamber 
2. No tendency to recurrence
3. Corneal hypoesthesia
4. All of the above 

3. Which of the following is false about acyclovir – 

1. Topical acyclovir is less effective than oral acyclovir in the treatment of herpes simplex epithelial keratitis
2. Valacyclovir is the prodrug of acyclovir
3. The dosing frequency is less with valacyclovir than acyclovir
4. Oral acyclovir given daily can reduce the recurrence of herpes simplex epithelial keratitis

4. Acyclovir is preferred treatment for : 

1. Patient physically unable to use gel or drops (i.e., patients with intention tremor or arthritis). 
2. Contact lens wearers.
3. Pediatric patients’ refractory to topical antiviral.
4. Patients that require lengthy treatment antiviral agents (greater than 21 days).

5. In the treatment of herpes simplex stromal disease, Herpetic Eye Disease Studies (HEDS) show that:

1. topical steroid reduces the duration of the disease
2. patients on topical steroid has better visual outcome at six months review than the non-steroid treated group
3. topical steroid increases the likelihood of epithelial disease
4. oral acyclovir has added benefit in patients treated with topical steroid and trifluridine

1. Answer – b : Ocular disease is most common manifestation of primary type I herpes simplex. 

Type II herpes is associated with genital herpes, infants passing through the infected birth canal can acquire ocular disease. Oral disease is more common than ocular herpes in case of primary type I herpes simplex. Human is only natural reservoir of herpes simplex. Genital and oral recurrence are commoner than ocular recurrence in herpes simplex.

Reference – Whitley RJ, Roizman B. Herpes simplex virus infections. The lancet. 2001 May 12;357(9267):1513-8. https://doi.org/10.1016/S0140-6736(00)04638-9

2. Answer – c : Corneal hypoesthesia

Visually significant complications associated with HSV keratitis, such as lipid keratopathy, corneal thinning, and neurotrophic cornea, arise from the complex interplay between viral activity and the host immune response. Confocal microscopy studies have shown that corneal dendritic cells continually evolve in density, distribution, and morphology during active herpetic endothelitis. Corneal nerve degeneration often results in significantly reduced corneal sensation. 

Reference – Valerio GS, Lin CC. Ocular manifestations of herpes simplex virus. Current Opinion in Ophthalmology. 2019 Nov 1;30(6):525-31.doi: 10.1097/ICU.0000000000000618.

3. Answer – a : Topical acyclovir is more effective than oral acyclovir in the treatment of herpes simplex epithelial keratitis

Both topical and systemic acyclovir are equally effective in the treatment of herpes simplex epithelial keratitis. Oral acyclovir reduces the ocular complication of herpes zoster ophthalmicus but does not reduce the incidence and severity of post herpetic neuralgia. 

Reference – White ML, Chodosh J. Herpes simplex virus keratitis: a treatment guideline. Hoskins Centers Compendium of Evidence-Based Eye Care. 2014 Jun. https://pdfs.semanticscholar.org/31e6/52d3851463d67a59e881e1ac8988495e212e.pdf

4. Answer – c : Contact lens wear

Trifluridine treatment is limited to 21 days, Trifluridine approved for children age 6 and older. Ganciclovir is warned against contact lens use for treatment of active herpes keratitis due to the potential link between herpes keratitis recurrence and contact lens use.

Reference – Chou TY, Hong BY. Ganciclovir ophthalmic gel 0.15% for the treatment of acute herpetic keratitis: background, effectiveness, tolerability, safety, and future applications. Therapeutics and clinical risk management. 2014;10:665. doi: 10.2147/TCRM.S58242

White ML, Chodosh J. Herpes simplex virus keratitis: a treatment guideline. Hoskins Centers Compendium of Evidence-Based Eye Care. 2014 Jun. https://pdfs.semanticscholar.org/31e6/52d3851463d67a59e881e1ac8988495e212e.pdf

5. Answer – a : Topical steroid reduces the duration of the disease

HEDS shows that topical steroids reduce the severity and the duration of herpes simplex stromal disease. However, there is no  significant difference in visual outcome between those treated with steroids and those treated with placebo. There is no increase in epithelial disease during topical steroid treatment. The study did not look into necrotising stromal keratitis. Oral acyclovir does not appear to have added benefit in those patients treated with topical steroids and trifluridine during primary treatment, however it has shown to prevent recurrences. 

Reference – Wilhelmus KR, Gee L, Hauck WW, Kurinij N, Dawson CR, Jones DB, Barron BA, Kaufman HE, Sugar J, Hyndiuk RA, Laibson PR. Herpetic Eye Disease Study: a controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology. 1994 Dec 1;101(12):1883-96. https://doi.org/10.1016/S0161-6420(94)31087-6