Cold Sore in the Eye? Can that really happen? YES!

Most people hear the word “herpes” and immediately think sexually transmitted disease. However there are different types of herpes viruses. Cold sores are caused by Herpes Simplex (HSV) Type 1 whereas sexually transmitted herpetic disease is caused by HSV type 2 so essentially we have above the waist HSV and below the waist HSV.

According to the World Health Organization, 67% of the population under the age of 50 is infected with HSV Type 1. Transmission is usually caused by contact with an individual who has an active HSV outbreak in the form of a cold sore or other lesion. After initial infection, the patient may or may not have symptoms and the HSV virus is recognized by your immune system which then produces an antibody to fight the infection. The HSV virus is very elusive and will hide in nervous tissue but the immune system is smart and will normally keep the virus contained.  However, during times when the immune system is not functioning properly, particularly during times of stress or other illness, the HSV virus can break into the immune system’s jail and spread down the facial nerve endings usually to the lips but sometimes to the eyes.

The most common symptom of an HSV outbreak in the eye is a sudden foreign body sensation when the patient is not in an environment where something could have lodged on the surface of the eye. Example, just sitting at your desk and suddenly you feel like something is in your eye versus raking leaves or sanding something when an actual particle may be embedded in the eye. This is very important in the case history part of the diagnosis. Patients also may experience eye pain, light sensitivity, or blurry vision. Asking questions regarding recent life stressors or other illnesses is also very important in the diagnosis.

Diagnosis of ocular HSV requires an eye doctor to examine the patient with a microscope. This cannot be done at your local urgent care or minute clinic. The eye doctor will use special dyes to “stain” the surface of the eye. The HSV lesions will then be visible on the cornea (front surface of the eye) or surrounding tissues. Pustules may also be present on the eyelids. Proper diagnosis of HSV is essential and can often be very difficult as every patient has a different presentation of the disease.

Treatment of HSV is fairly simple once the proper diagnosis is made. Since HSV is a virus, antibiotics are ineffective and the use of any steroid drops (further suppress immune system) will make the HSV spread like wild fire! Previous to recent advancements in oral antivirals, Viroptic eyedrops (four times per day for 7-14 days) were very effective but patients often do not like eye drops and the orals are just as effective. I tend to start patients on orals (Valtrex or lesser expensive Acyclovir) but will often use Viroptic eye drop in addition to the orals in more severe cases.  Since your immune system can never fully eradicate the HSV, many patients have recurrent outbreaks.  If this is the case, I often prescribe low dose oral antivirals for one to two years.

Remember a sudden foreign body sensation in the eye is the most common symptom of an HSV outbreak in the eye.