VOLUME 2, NUMBER 8

JUNE 27, 2011

ALTHOUGH AN HSV MARGINAL ULCER IS A RARE PRESENTATION, YOU MUST KNOW HOW TO MAKE A PROPER DIAGNOSIS.

This patient presented with an HSV marginal ulcer that exhibited deep neovascularization and no clear limbal zone. Click here to view larger image.

A staphylococcal marginal ulcer is a more common condition that often presents in patients with significant blepharitis. The classic appearance consists of an infiltrate surrounded by superficial blood vessels. On the other hand, marginal uclers caused by herpes simplex virus (HSV) are rarer than those caused by Staph. infiltrates, but also are more difficult to diagnose.

Staphylococcal marginal ulcers are commonly treated with a steroid combination agent, such as Zylet (loteprednol and tobramycin, Bausch + Lomb); however, steroids are completely contraindicated in the management of HSV ulcers. Instead, you should prescribe Zirgan (ganciclovir ophthalmic gel, Bausch + Lomb) five times a day until the ulcer resolves, then t.i.d. for an additional week. So, needless to say, the differential diagnosis is critical.

Fortunately, these three primary findings can help you differentiate between the two presentations:

• Patients with an HSV ulcer typically present with significantly more pain and inflammation. Often, these patients can barely open the afflicted eye during an examination.
• HSV ulcers exhibit deep stromal neovascularization, whereas Staph. marginal ulcers demonstrate superficial neovascularization.
• There is no clear zone between the limbus and the infiltrate in HSV ulcers. In fact, because of the presentation's severity, the managing clinician usually will observe nothing more than haze, neaovascularization, edema and an infiltrative response at the corneal-limbal junction.

"Time flies. It's up to you to be the navigator."
–Robert Orben