Ocular Herpes (eye herpes)
When one of the herpes viruses, herpes simplex 1 or herpes zoster, manifests in the eyes, it is called ocular herpes or herpetic eye disease. Ocular herpes may cause scarring, chronic inflammation, lesions, and ulcers that damage different layers of the cornea. It is the most common infectious cause of corneal blindness in the U.S.
Many people become infected with one of these viruses during childhood; they can be passed from one person to the other because the virus is contained in the moist skin that lines the mouth. In many people, the primary infection does not cause any symptoms. The most common time for a first active infection is between the ages of 30 and 40, and it may be more common in people who wear contacts. Because it affects the nerves directly, herpetic eye disease can be very painful.
Both viruses never leave the body after an initial infection; this can result in periodic flare-ups through one’s life, causing potential pain, including in the face and eyes. It is not known why the virus can suddenly flare-up, but it may be due to stress, low immunity, and/or trauma.
Most flare-ups will resolve within a few weeks in non-immunocompromised people, and in some, flare-ups can recur through one’s lifetime, possibly posing sight threatening eye problems.
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What is Ocular Herpes?
Herpes simplex keratitis occurs when the herpes simplex 1 virus (HSV) infects the cornea or the white part of the eye. The term keratitis means an inflammation of the cornea. The virus first attacks the corneal epithelium, the thin outer layer of the cornea. This layer plays an important role in protecting the eye. It blocks intrusion from foreign materials and provides a smooth surface to absorb oxygen and cellular nutrients that are delivered through the tear film that lies on top of it. The epithelium also contains many nerve endings; it’s very sensitive.
When a virus attacks the cornea, this outer epithelium layer becomes red, irritated, and painful, because the nerve endings serving the cornea also become infected. The extent of damage can vary widely, sometimes healing by itself within a week to ten days. If the virus recurs at a latter time, however, the results can be more serious, including ulcers and lesions that extend to the stroma layer of the cornea. The stroma layer is a thick layer comprised of water, layers of protein fibers, and cells delivering nourishment.
There are two major types of this virus. Type I is the most common and is not sexually transmitted, while Type II typically infects the genitals. Of the two types, Type I more commonly affects the eye, often resulting in symptoms such as eye infections, cold sores, or blisters.
Herpes zoster ophthalmicus, which has initial symptoms that may be similar to herpes simplex keratitis, occurs when the varicella zoster virus, dormant in most people, attacks the ophthalmic nerve. It spreads to the epithelial layer of the cornea, then to the stroma layer. In 40–50% of cases, anterior uveitis also develops. Skin rashes around the eyes are another characteristic result.
Types of Viruses
Two types of viruses are found: herpes simplex 1 (cold sores, herpes) and varicella zoster (chicken pox, shingles), causing herpes simplex keratitis and herpes zoster ophthalmicus, respectively.
Herpes simplex 1 virus is common; 50–80% of Americans carry the antibodies, depending on the socioeconomic group, and ocular infection from this virus affects about .008% to .03% of the population.
Varicella zoster virus was once very common; in the pre-inoculation era, 95% of children had the varicella antibodies before age 20. It is still carried by about 20% of the population. About 1% of these people develop herpes zoster ophthalmicus.
Types of Ocular Herpes
Herpes Simplex Keratitis
Primary HSV. Once a person is infected, this virus may manifest as herpes simplex 1 or become dormant. If dormant, it remains dormant until some stress triggers an outbreak. This initial outbreak is rarely noticed and rarely affects the cornea. Sometimes a patient will have an episode of conjunctivitis or blepharitis that resolves itself.
Recurrent HSV. If HSV recurs, it most often affects the cornea, resulting in herpes simplex keratitis. Although it usually affects the cornea, it can cause retinitis, trabeculitis (inflammation of the trabecular meshwork), anterior uveitis, and optic neuritis.
Epithelial keratitis. This is the most common and mildest form. It affects only the top epithelial layer of the cornea. Inflammation of the epithelial layer of the cornea takes the form of several types of sores or ulcers. They are identified according to their shape and location.
Stromal keratitis. Inflammation of a deeper layer of the cornea, the stroma, is more often associated with immune system issues; it can be quite serious, resulting in permanently blurred vision and blindness. It can manifest as a wide range of interrelated conditions. Some of these include interstitial keratitis (affecting spaces between cells), necrotizing keratitis, disciform keratitis (disc-shaped corneal swellings), and keratouveitis (uveitis predominates). Stromal keratitis develops in about 25% of those people who have epithelial keratitis.
Recurrence. Recurrence of epithelial or stromal keratitis is 10% after 1 year, 23% after 2 years, and 50% after 10 years.
Herpes Zoster Ophthalmicus
Like the herpes simplex 1 virus, the herpes zoster virus can cause an initial outbreak, or it can remain dormant in the body. If there is a recurrence, often triggered by emotional or environmental stress, not only the skin (shingles) but the cornea can be impacted. And, like the herpes keratitis, the epithelial or stroma layer can be affected.
Epithelial punctate. Epithelial erosions manifest with ulcers or lesions on the surface of the cornea.
Nummular keratitis. If the stroma layer is involved, it is called nummular keratitis, which occurs with granular deposits in the stroma layer, or necrotising interstitial keratitis, which occurs with leaking into the stroma, corneal thinning, and sometimes perforated cornea.
Disciform keratitis. This form displays corneal edema, and it folds in the Descemet's membrane.
Neurotropic. This form involves damage to the nerves in the cornea, causing corneal damage, thinning, and sometimes perforation.
Iridocyclitis or anterior uveitis. These can develop from the zoster virus. Not only is the cornea affected, but also the deeper tissues of the iris is affected that causes severe light sensitivity, blurred vision, pain, and redness.
Ocular herpes is characterized by a painful sore on the eyelid or on the surface of the cornea of the eye.
- Infection of conjunctiva and eyelids that heals without scarring
- Recurring eye infections
- Blurry vision
- Redness and sores
- Tearing and discharges
- Eye sensitivity and light sensitivity
There are a few other symptoms that help differentiate between the two forms.
Herpes Simplex Keratitis
- A feeling of grit or dirt in the eye
- Tearing and discharge
- Pain, especially when looking at bright light
- Conjunctiva infection that heals without scarring
Herpes Zoster Ophthalmicus
- Headache and fever
- Rash or sores on forehead, eyelids, around the eyes, and sometimes the tip of the nose
- Blurry vision
Ocular herpes is caused by infection from others or self-infection from a cold sore. Because the virus can lie dormant for years, it may be inactive and become active in times of stress, sunburn, trauma, etc.
- An imbalance of the amino acids argine and lysine in the body makes us more vulnerable. Arginine is necessary for HSV to grow, suggesting supplementation with lysine.
- Stress causes the immune system to be less effective
- Excess sugar increases the risk and severity of outbreaks
- People who have had ocular herpes previously should avoid arginine supplementation.
- Dry eye may be a stressor contributing to outbreaks of the condition.
- Certain medications have been linked to ocular HSV reactivation, including beta-blockers, immunosuppressing drugs, particularly those with topical ocular corticosteroids, epinephrine, and prostaglandins. There is also a possible link to excimer laser treatment.
Treatment depends on the form of the condition. Initial treatment is with either topical eyedrops or oral antiviral medication, such as Viroptic (trifluridine, GlaxoSmithKline), which is the cornerstone of topical treatment for herpes simplex keratitis. Treatments typically last 1–2 weeks, depending on healing time. Eyedrops called corticosteroids can help control the disease, but they can also raise the pressure in the eyes for some people, in which case additional eyedrops may be prescribed along with the corticosteroids to keep the pupil dilated that helps prevent the eye pressure from increasing due to corticosteroids.
In certain less-common cases, intravenous medication may be necessary, using antiviral drugs such as Acyclovir, and more recently Valacyclovir, to suppress the reproduction of the virus. Multiple treatments with steroids may be required if the middle layer of the cornea (herpetic stromal keratitis), back layer of the cornea (herpetic endotheliitis), and/or the iris (herpetic iritis) are affected.
Herpetic iritis is also treated with aggressive steroid use, including hourly prednisolone acetate and cycloplegia as cornerstone therapies.
In addition to your eye doctor’s recommendations some natural solutions such as l-lysine and curcumin may be helpful in milder versions of an outbreak or lessen the risk of recurrence. Targeted antioxidants may help neutralize free radicals that result from inflammation, and certain natural eyedrops can help reduce the symptoms.
Although more research is needed, some studies have found that lysine, or L-lysine, an essential amino acid, taken on a regular basis may help prevent outbreaks of cold sores and genital herpes. Because L-lysine blocks the activity leading to HSV development. One study found that L-lysine was better at preventing than curing herpes, and another found that taking it at the beginning of an outbreak did not reduce symptoms. Our recommendation therefore, is that because this condition can repeat, if you have it one time, you increase L-lysine in your diet to try to prevent future outbreaks.
Talk to your doctor about your proper dosage. It is considered safe, but high dosages might cause gallstones, renal dysfunction. People with kidney or liver disease, and pregnant women should talk to their doctor.
- Supplementation with helpful nutrients and eyedrops that have been found to be helpful for ocular herpes.
- Reduce or eliminate refined, white foods from your diet including white sugar, flour, pasta and white rice from your diet. These foods reduce your immune system's ability to fight outbreaks and new infections.
- Allergens Identify and avoid foods and/or chemicals you may be allergic to.
- L-Arginine Avoid foods (like cashews) that contain L-arginine, because this amino acid may facilitate outbreaks. Other foods high in arginine are chocolate, peanuts and almonds.
- Supplement with organic style vitamins and minerals including the following:
- Anti-virals such as Wild Oregano Oil, Monolaurin capsules, Coconut oil by mouth, Camu Camu - in large doses
- Anti-inflammatory - Turmeric capsules, or turmeric in your cooking
- Anti-inflammatory/Anti-scar tissue - Bromelain, porteolytic enzymes like "Zygest"
- Vision support L-lysine is an amino acid, which some practitioners say is helpful, others disagree.
- Immune support - Colostrum with lactoferrin, Host defense (multiple mushroom formula by NewMark
- Herpes DNA breaking - Licorice extract in liquid form is said to break the DNA chain of herpes so that it cannot multiply.
- Toxin absorption King chlorella absorbs the toxins released by dying herpes virus
- Ocular Herpes Juicing Recipe Favor these juicing ingredients to supplement your diet if you have ocular herpes.
- Diet & lifestyle protocol - see our general recommendations for supporting vision for detailed information.
Ocular Herpes News
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Although the underlying physiological cause may be unique, there may be similarities in terms of nutritional, diet and lifestyle recommendations made by Dr. Grossman for eye conditions that result in similar vision symptoms to those of ocular herpes.
JAMA. 2006 Aug 23;296(8):964-73:, Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, Berman SM,
L-lysine. Monograph, Altern Med Rev. 2007 Jun;12(2):169-72.
Natural remedies for Herpes simplex., Altern Med Rev. 2006 Jun;11(2):93-101. Gaby AR.
- Blepharitis - inflammation and/or infection of the eyelids.
- Conjunctivitis (pink eye) - inflammation and/or infection of the conjunctiva, the moist membrane lining the eye and eyelid.
- Uveitis - inflammation of the middle layer of the eye, the uvea, a contributing factor to more serious conditions.
- Blepharoconjunctivitis - combining a severe case of blepharitis and conjunctivitis.