“Symptoms can range from foreign body sensation to pain out of proportion to the clinical appearance,” Dr. “Suspect if the infectious keratitis lasts more than 2 weeks.”Īcanthamoeba may be to blame if a patient has a history of improper contact lens wear and hygiene, and uses contacts while swimming or in hot tubs.

“The patient has already undergone treatment with either oral or topical antivirals,” Dr. In neurotrophic epitheliopathy, the pseudodendrite is often in the interpalpebral region of the cornea. Pseudodendrites have a wide variety of causes including neurotrophic epitheliopathy, Acanthamoeba, healing epithelial defect, and recurrent erosion syndrome, Dr. They’re also more superficial and have no central ulceration. Neurotrophic epitheliopathy pseudodendriteįurthermore, VZV is typically found in the periphery of the cornea, Dr. VZV can take on a medusa-like form, with its many branches and lack of end bulbs. It has a “stuck on appearance” that’s elevated and presents as “convoluted clusters,” Dr. For example, unlike HSV, which stains brightly, VZV stains minimally. Varicella zoster (VZV) dendrites are quite different from HSV. “We call them pseudodendrites because they are not herpes simplex, but they are in fact dendrites.” “The term pseudodendrite is a little bit of a misnomer,” Dr. “Many clinicians associate prior topical steroid use with geographic ulcers, but a geographic ulcer from HSV may form without prior topical steroid use as well,” Dr. A classic clinical observation is a scalloped-shaped boarder, not to be confused with healing abrasions and epithelial defects from neurotrophic keratopathy, which have smooth borders. If a patient has an enlarged dendrite that’s not linear, it’s a geographic ulcer. On the other hand, patients with recurrent HSV keratitis and intact immune systems may have these vesicles early on in a recurrence prior to examination. For example, immune-compromised patients may have vesicles only and no dendrite, said Dr. HSV, however, doesn’t always present this way.

“The virus bounces from cell to cell, so each lesion develops one cell at a time, which is why you get this linear lesion because there are cells falling out and virus cells filling in,” Dr. “Within approximately 24 hours, these vesicles coalesce to form the classic dendrite that most ophthalmologists recognize.” “Vesicles should not be confused with punctate epithelial erosions, which stain positively with fluorescein,” Dr. Vesicles will form and appear as small, raised lesions at first and will not stain with fluorescein. Chan, M.D., professor of ophthalmology, University of Toronto. True HSV also progresses in stages, said Clara C. Clara Chan, M.D., and Mark Mannis, M.D., give us their insights for the examination of the patient with a “dendrite.” In addition, the label of HSV is often permanently attached to the patient.Ī detailed history, careful slit lamp examination, and close monitoring of the clinical course will assist the clinician in determining the correct diagnosis and treatment for these challenging patients. These patients are often placed on topical antivirals, which leads to delayed epithelial healing and persistence of this pseudodendrite. It is very common to see patients with healing epithelial defects or neurotrophic epitheliopathy present with a “dendrite” or a branching epithelial lesion. There are many other “dendritic” lesions of the corneal epithelium that are not due to HSV and have been referred to as “pseudodendrites.” It is important for clinicians to realize that a dendrite (referring to the shape) is not always the infectious epithelial lesion of HSV. When clinicians see a “branching treelike figure” in the corneal epithelium, the most immediate thought is herpes simplex virus (HSV) keratitis. The term dendrite is defined as a branching treelike figure.

Dendrite labeled