Herpes Simplex Keratitis
What Is Herpes Simplex Keratitis?
HSK develops when the herpes simplex virus reaches and infects the cornea, causing inflammation that can range from mild surface irritation to deeper, more serious damage. Understanding what type of infection is present helps your eye doctor guide the right treatment and prevent complications.
Herpes simplex keratitis most commonly involves type 1 of the herpes simplex virus, though type 2 can also cause corneal infections. The virus lives within nerve tissue and can travel to the eye even in people who have never noticed a visible cold sore. Once it reaches the cornea, it can damage surface cells, deeper layers, or both, depending on how the infection develops.
Epithelial keratitis affects only the outermost layer of the cornea, called the epithelium. When examined using special dye and light, this type typically shows a distinctive branching, tree-like pattern called a dendritic ulcer. A larger, irregularly shaped version of this pattern is called a geographic ulcer. Epithelial keratitis generally responds well to antiviral treatment.
Stromal keratitis goes deeper into the middle layers of the cornea and carries a higher risk of scarring and lasting vision problems. There are several forms, including immune stromal keratitis, where inflammation occurs without active virus in the tissue, and stromal necrosis, a rarer and more severe form. Endotheliitis, also called disciform keratitis, affects the deepest corneal layer and can cause significant swelling and cloudiness.
HSK is often confused with pink eye, but the two conditions are quite different. Pink eye (conjunctivitis) affects the clear membrane lining the inside of the eyelids and the white of the eye, while HSK targets the cornea directly and can blur vision. Redness from HSK often appears most prominently around the colored part of the eye rather than spreading evenly across the white. HSK also carries a greater risk of serious complications, including permanent vision loss, which is why accurate diagnosis matters so much.
After the first episode, the herpes simplex virus does not leave the body. It retreats into nearby nerve tissue and can remain dormant for months or years before reactivating. Each recurrence carries a renewed risk of deeper corneal damage, making long-term monitoring and, in some cases, preventive treatment an important part of care.
Recognizing the Symptoms of HSK
The symptoms of HSK can vary in severity, and some patients experience less discomfort than expected because the virus can reduce sensation in the cornea over time. Knowing what to look for helps you seek care promptly and avoid complications.
Eye pain is a common symptom, though its intensity varies from person to person. Redness tends to be most noticeable around the colored part of the eye, a pattern called limbal or ciliary injection. Excessive tearing is also common as the eye reacts to infection, and this is typically different from the discharge seen with ordinary pink eye.
Many people with HSK find bright light uncomfortable or even painful, a condition called photophobia. Blurring of vision can develop as inflammation and swelling build up in the cornea. The blurriness may start as mild haziness and worsen if the infection is not treated promptly.
A gritty or scratchy feeling is a very common complaint with HSK, even though nothing is actually in the eye. This sensation comes from damage to the corneal surface and can feel like sand or an eyelash trapped under the lid.
- The discomfort may be constant or worse with blinking
- Rubbing your eye will not help and may make things worse
- The feeling usually affects only one eye
Some symptoms point to a more serious infection or complication and require same-day evaluation. Sudden or severe vision loss, intense pain that does not improve, or visible white or cloudy patches on the cornea are all urgent warning signs. Halos around lights combined with eye pain, severe headache or nausea alongside eye symptoms, and an inability to keep the eye open due to pain or sensitivity all warrant immediate attention. Contact lens wearers who develop sudden pain, redness, or vision changes should seek care right away, as several serious infections share these features and require prompt treatment.
Who Gets Herpes Simplex Keratitis?
HSK can affect people of many different backgrounds, but certain factors increase the risk of developing the infection or experiencing recurrences. Identifying these factors helps your eye doctor tailor your care and monitor you more closely when needed.
Anyone who carries the herpes simplex virus is at risk for HSK, including people who have had cold sores around the mouth or nose. The virus can travel along nerves to reach the eye even when no active sore is visible. People with a history of genital herpes, most often caused by type 2, can also develop eye infections, though this is less common.
Conditions and medications that lower immune function make it easier for the dormant virus to reactivate. This includes certain autoimmune diseases, cancer treatments, and long-term use of immune-suppressing medications. People in these situations are at higher risk for more severe or frequent episodes and should be seen promptly for any new eye symptoms.
- Organ transplant recipients taking anti-rejection medications
- Patients undergoing chemotherapy or radiation
- People living with HIV or other immune disorders
- Those taking long-term or high-dose corticosteroids
An injury to the eye or certain eye surgeries, including LASIK or cataract surgery, can trigger reactivation of the herpes virus in people who already carry it. Contact lens wear does not cause HSK on its own, but improper lens hygiene can disrupt the corneal surface and increase overall infection risk. If you have a history of HSV, your eye doctor may recommend extra precautions with contact lens use.
Physical or emotional stress can lower the body's defenses and allow the virus to reactivate. Fever, illness, sleep deprivation, and prolonged sun exposure have also been identified as potential triggers. Many patients notice their episodes tend to occur during or just after periods of high stress or fatigue, and recognizing these patterns can help you stay alert for early symptoms.
How We Diagnose HSK
Accurate diagnosis is the foundation of safe and effective treatment. We combine a careful review of your history with a thorough examination to confirm the type of infection and rule out other conditions that can look similar.
We start by asking about your symptoms, how long they have been present, whether you have had similar episodes before, and whether you have a history of cold sores or herpes infections. During the examination, we assess your vision, check the pressure inside your eye, and look closely at the cornea and surrounding structures for signs of inflammation or damage.
We place a safe orange dye called fluorescein on the surface of your eye. Under a special blue light and a slit lamp microscope (a magnified instrument used to examine the eye in detail), areas of corneal damage glow bright green. Epithelial HSK often reveals a distinctive branching pattern called a dendritic ulcer, which helps confirm the diagnosis and distinguish it from other types of corneal disease.
Most cases of HSK are diagnosed based on the clinical appearance of the cornea without needing lab tests. Testing is reserved for atypical presentations, severe or recurrent infections, disease that does not respond to treatment, or cases where the diagnosis is uncertain, particularly in patients with weakened immune systems.
- Polymerase chain reaction (PCR) testing for rapid, accurate virus detection
- Viral culture to identify the virus, though results take longer
- Corneal scraping to examine cells under a microscope
- Anterior segment imaging to assess stromal swelling or scarring when needed
Several other infections and inflammatory conditions can look like HSK, and careful differentiation is essential before starting treatment. Bacterial keratitis, acanthamoeba (a water-related corneal infection common in contact lens users), varicella zoster virus infections, fungal keratitis, and certain autoimmune conditions can all affect the cornea in ways that resemble HSK. Using steroid drops for an infection that has not been properly identified can lead to serious complications, so we take care to be confident in the diagnosis before recommending any treatment.
Treatment Options for Herpes Simplex Keratitis
Treatment for HSK is tailored to the type, depth, and severity of your infection. Our goal is to clear the active infection, protect your vision, and reduce the risk of future episodes.
Antiviral medications are the cornerstone of HSK treatment and work by stopping the virus from replicating. Depending on the type of infection, your overall health, and what is most appropriate for your situation, we may prescribe antiviral eye drops, oral antiviral pills, or a combination of both.
- Topical ganciclovir gel or trifluridine drops for epithelial disease
- Oral acyclovir, valacyclovir, or famciclovir for deeper infections, recurrences, and use in immunocompromised patients
- Long-term suppressive oral antiviral therapy to prevent recurrences in patients with frequent or severe episodes
- Dose adjustments for patients with kidney disease who need oral antiviral medications
Antibiotic drops are not used to treat HSK but may be added if there is concern about a secondary bacterial infection accompanying significant corneal breakdown.
Corticosteroid drops reduce inflammation and can help prevent scarring in certain forms of HSK, particularly stromal keratitis, endotheliitis, and HSV-related inflammation inside the eye (anterior uveitis). However, steroids are generally avoided when there is active epithelial HSK because they can allow the virus to spread and cause serious worsening of the infection. When steroids are appropriate, they are always used alongside antiviral coverage and require close monitoring by an ophthalmologist, including regular checks of eye pressure.
Debridement is a procedure where we gently remove infected cells from the surface of the cornea using a cotton swab or similar instrument. This reduces the amount of active virus on the eye and can speed up the healing process. The procedure is performed with numbing drops in the office and is followed by antiviral treatment. Most patients tolerate it well and notice improvement within a few days.
Stromal keratitis requires a more prolonged treatment approach with careful monitoring. Extended antiviral therapy and a slow, supervised reduction of steroid drops help prevent rebound inflammation and scarring. Repeated infections can lead to neurotrophic keratopathy, a condition where the cornea loses sensation and has difficulty healing, requiring specific supportive care including lubrication and epithelial surface management.
- Extended oral antiviral therapy to suppress the virus during treatment
- Gradual tapering of steroid drops to avoid rebound inflammation
- Additional medications to manage elevated eye pressure when needed
- Consideration of corneal transplant surgery if scarring is severe and vision is significantly reduced
Even with proper treatment, HSK can lead to complications such as elevated eye pressure, cataract development, or corneal scarring. We schedule regular follow-up visits to track your progress, check for complications, and adjust your treatment plan as your eye heals. If you notice any new or worsening symptoms between visits, contact us right away.
Caring for Your Eyes During and After Treatment
The steps you take at home during and after treatment play an important role in recovery and in reducing the risk of future episodes. Following your treatment plan closely and taking care of your eyes daily supports the best possible outcome.
Washing your hands thoroughly before and after applying eye drops is one of the most important things you can do during treatment. Avoid touching or rubbing your affected eye, as this can spread the virus or introduce new bacteria.
- Use a clean tissue to blot away excess tearing rather than wiping
- Avoid eye makeup until the infection has fully resolved
- Wear sunglasses outdoors to ease light sensitivity
- Get adequate rest and stay well hydrated to support healing
- Do not share towels, washcloths, or eye drops with others
- Do not use leftover steroid drops or over-the-counter numbing drops on your own
- Do not patch the eye unless your eye doctor specifically instructs you to do so
You should not wear contact lenses during an active HSK infection. Lenses can interfere with healing and increase the risk of additional infection. Once your eye has fully healed and your eye doctor has confirmed the infection is resolved, we will discuss when and whether it is safe to return to lens wear. Any lenses and lens cases used around the time of your infection should be discarded and replaced before resuming wear.
It is critical to finish the full course of antiviral medication even if your symptoms improve quickly. Stopping treatment early can allow the virus to resurge, slow healing, and increase the risk of recurrence or a more serious infection. If you experience side effects, let us know rather than stopping on your own. We can often adjust the dose or find a better-tolerated alternative.
Because the herpes virus remains in your body after the first episode, reducing recurrences is an ongoing part of your care. Managing stress, maintaining regular sleep, protecting your eyes from injury, and attending scheduled follow-up visits all help lower the chance of reactivation. For patients with frequent or severe episodes, long-term suppressive antiviral therapy can significantly reduce future flare-ups and protect long-term vision.
Frequently Asked Questions
The following questions address common concerns patients have about managing HSK, making decisions about care, and knowing when to seek help.
The herpes simplex virus can be transmitted through direct contact with active secretions or lesions, such as touching an infected area and then touching another person. Eye-to-eye spread is uncommon in everyday settings but is possible if you touch your infected eye and then touch someone else's eye or your own other eye. Washing your hands frequently and avoiding touching your eyes is the most practical way to prevent spread. If you notice symptoms developing in your other eye, contact us promptly rather than waiting.
Uncomplicated epithelial keratitis typically improves within one to two weeks with antiviral treatment. Stromal keratitis takes considerably longer and may require several weeks to months of medication and close follow-up. Your healing time depends on how severe the infection is, how quickly treatment was started, and whether any complications arise. We will give you a clearer timeline based on what we observe at your follow-up visits.
Many people recover well from a first episode of epithelial HSK without lasting vision problems, particularly when treatment begins promptly. The risk of permanent vision change increases with repeated infections, stromal involvement, and complications from treatment. Corneal scarring is the most common cause of long-term vision reduction in patients with recurring HSK. Consistent management and attendance at follow-up visits give you the best chance of preserving clear vision over time.
Some patients are able to return to contact lens wear after the cornea has fully healed and your eye doctor has confirmed recovery is complete. This decision depends on how often you have had HSK episodes, how much corneal involvement there was, and your lens hygiene habits. In some cases, switching to daily disposable lenses or wearing glasses may be the safer long-term choice. We will work with you to find the option that best balances your vision needs and your eye health.
There is currently no vaccine available to prevent herpes simplex virus infection, and no treatment fully eliminates the virus from your body. However, antiviral medications are highly effective at controlling active infections, and long-term suppressive therapy can meaningfully reduce the frequency of recurrences. Most people with HSK, with proper management, are able to maintain good vision and quality of life over the long term.
If you have a known history of HSK and notice familiar symptoms returning such as eye pain, redness, light sensitivity, or blurring, contact your eye doctor as soon as possible rather than waiting to see if things resolve on their own. Early intervention is the most effective way to prevent a recurrence from progressing to deeper, more damaging disease. Do not use leftover prescription drops from a previous episode without guidance, as the correct treatment depends on the current type of infection.
See Our Team at ReFocus Eye Health Camden
If you are experiencing eye pain, redness, light sensitivity, or changes in your vision, our team at ReFocus Eye Health Camden is here to help with a thorough evaluation and a personalized treatment plan. We bring expertise in corneal disease and general ophthalmology to patients throughout the region, with a focus on protecting your sight for the long term. Early care makes a meaningful difference with HSK, and we are committed to being your trusted partner through every stage of diagnosis, treatment, and follow-up.
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