Kerala Journal of Ophthalmology

: 2022  |  Volume : 34  |  Issue : 1  |  Page : 47--50

Spectrum of herpetic eye disease during COVID-19 pandemic

Shruti Bhat1, Pallavi Joshi2, Anand Balasubramaniam1, Yash Gala1,  
1 Department of Cornea and Refractive Services, Sankara Eye Hospital, Bengaluru, Karnataka, India
2 Department of Cornea, Ocular Surface and Refractive Services, Sankara Eye Hospital, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Pallavi Joshi
Department of Cornea, Ocular Surface and Refractive Services, Sankara Eye Hospital, Bengaluru, Karnataka


Purpose: To analyze clinical presentation, outcome and upsurge in the acute presentation of Herpetic eye disease (Herpes simplex keratits and Herpes Zoster Ophthalmicus) cases during coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: Retrospective analysis of case records of patients diagnosed with either acute HSV or HZO from April 2020 to March 2021 for demography, ocular manifestations, and management and clinical outcome was done. Results: We had 71 patients presenting to our hospital with herpetic eye disease with 50.70% being HZO. The majority (64.78%) of the patients were <50 years of age. The mean time to presentation from the onset of symptoms was earlier in HZO compared to HSV. Three patients were post-COVID-19 infection while six patients were post-COVID-19 vaccination. Stromal keratitis (48.5%) was the most common presentation in patients with HSV while keratitis and uveitis (31.57% each) were the most common presentation in HZO. 83.08% resolved without any visual sequelae. We also observed atypical presentation in the form of multidermatomal involvement and recurrence of keratitis in HZO patients. We observed an alarming two-fold increase in the number of cases that presented this year (2020–21) as compared to the same time (n = 33) in the past year (2019–20). Conclusion: This study highlights an increase in viral eye disease presenting atypically and higher incidence in young individuals during the COVID pandemic. Viral disease of the eye during the pandemic may be related to the altered immunity in coexisting asymptomatic COVID-19-infected patients and similar in postvaccinated individuals or the stress-induced immune alteration by the pandemic itself in healthy individuals. However, though this study suggests direct causal relation of either of the above as possibility and needs to be kept in mind in clinical practice, for definite association, we need further exploration and more data.

How to cite this article:
Bhat S, Joshi P, Balasubramaniam A, Gala Y. Spectrum of herpetic eye disease during COVID-19 pandemic.Kerala J Ophthalmol 2022;34:47-50

How to cite this URL:
Bhat S, Joshi P, Balasubramaniam A, Gala Y. Spectrum of herpetic eye disease during COVID-19 pandemic. Kerala J Ophthalmol [serial online] 2022 [cited 2023 Feb 8 ];34:47-50
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Full Text


Herpes simplex virus (HSV) and herpes zoster virus are DNA viruses belonging to the Herpes virus family. The virus remains dormant in the nervous tissue following primary infection. Failure of the immune system to contain the virus causes reactivation which is known to be triggered by immunosuppression, trauma, stress, radiation, certain mediation, and viral infections.[1],[2] Both these viruses are known to result in potential chronic ocular morbidity with substantial visual loss.

Herein, this study was aimed to analyze cases of new-onset Herpes simplex keratitis and Herpes zoster ophthalmicus (HZO) occurring in patients during the COVID-19 pandemic (April 2020–March 2021).

 Materials and Methods

Retrospective data of patients presenting to us in the outpatient department with acute HSV and HZO during the COVID-19 pandemic (April 2020–March 2021) was reviewed and analyzed.

To have a comparative data to assess the role of the COVID pandemic for the upsurge, the present results were compared to that of the previous year during the same period (2019–2020).


The study included a total of 71 patients with herpetic eye disease, of which 36 patients had HZO.

The demographic details are shown in [Table 1]. Of 71 patients, 45 were male and 26 were female. The age of the patients ranged from 12– 96 years with the majority (64.78%) being < 50 years of age. Five (7%) were pediatric cases. One patient was immune compromised. Only eight patients had comorbidities in the form of diabetes and hypertension. The presentation time to hospital from onset of symptoms ranged from 2–90 days with a more acute presentation of patients with HZO (mean time-5.07 days) compared to those with HSV (mean time-25.65 days).{Table 1}

The ocular involvement is as shown in [Table 2]. Stromal keratitis (48.5%) followed by epithelial disease (31.4%) were the most common presentation in patients with HSV [Figure 1]. Two patients had viral keratitis in the grafted eye (post-COVID vaccination). While, in patients with HZO, 52.8% had ocular involvement in whom keratitis and uveitis (6 patients each) were the most common presentation [Figure 2]a. In addition, atypical features in the presentation of HZO such as multidermatomal involvement [Figure 2]b, recurrence of keratitis (n = 1), and also patients who had corneal involvement (n = 10), 70% did not have tip of the nose involved, thus deviating from the Hutchinson sign were also observed.{Figure 1}{Figure 2}{Table 2}

There was marginally higher percentage of patients with involvement of the left eye (55.22%) compared to the right eye. Twelve patients developed significant visual morbidity due to extensive corneal scarring. However, the majority of the patients (83.08%) resolved without any visual sequelae.

The data analyzed showed that every patient was asked history for recent exposure, contact, or symptoms suggestive of COVID, but laboratory investigations for COVID-19 were not advised in these patients.

However, three patients were diagnosed with COVID-19 and presented to us postrecovery while three patients had been exposed to COVID-affected relatives in the previous 2 weeks before presentation. In addition to the above, we also had six patients developing herpetic eye disease within 2 weeks of COVID vaccination.

Surgical intervention was required in four cases of HSV presenting with perforation. Three patients underwent glue with bandage contact lens (BCL) while one patient underwent corneal patch graft. One patient managed with glue and BCL ultimately underwent keratoplasty after adequate control of the disease. One HZO case with neurotrophic ulcer underwent amniotic membrane transplantation with tarsorrhaphy.

Our study showed nearly two-fold increase in the number of cases that presented in (2020–21) as compared to the same time (n = 33) in the past year (2019–20).


COVID caused by severe acute respiratory syndrome coronavirus 2 has led to a global epidemic. The rapid progression of the COVID-19 pandemic has created tremendous challenges for health-care professionals worldwide.

COVID-19 is known to present with varied manifestations, and the eye is not an exception. COVID-19 as well as its therapy has been reported to have both direct and indirect effects on the eye.[3]

Knowledge about this disease is still evolving. Several studies reported that COVID-19 infection is associated mostly with reduction in the population of lymphocytes, monocytes, and eosinophils,[4],[5],[6],[7] especially with drastically low levels of CD4 + T cells, CD8 + T cells, B cells, and natural killer cells.[8] These cells are essential for an effective antiviral response. The immune system in COVID-19 patients demonstrates immunosuppression which is more severe in critically ill patients.[9] Our study showed two such patients who suffered from severe COVID-19 infection and developed HSV infection during the same period which reflects the same.

Studies have also reported lower percentages of T-cell functional markers in COVID-19 patients with decreased percentages of CD107a, interferon gamma (IFN-γ) +, interleukin-2, granzyme B +, and IFN-alpha when compared to normal controls correlating with functional exhaustion of cytotoxic lymphocytes.[10] The combination of these mechanisms leads to an impaired antiviral response in the host.[11] This could result in failure to maintain the latency of the virus and reactivation of the disease.

In addition to the above, many psychological problems such as stress, anxiety, depression, frustration, and uncertainty during COVID-19 outbreak have emerged progressively.[12] The physical and emotional stress during the pandemic could also be a possible triggering factor for reactivation of the virus.

Furthermore, with the recent introduction of vaccination, this study highlights a few cases of postvaccination viral keratitis. Chau et al. have observed the immunogenicity of COVID-19 vaccines could potentially induce or trigger autoimmune diseases.[13] There could be probable alteration of immune response in post-COVID vaccinated individuals which could potentiate reactivation of disease. However, it might be too early to comment a causal relation or to draw a conclusion as the data are limited.

Majtanova et al. have described five cases of Herpes simplex keratitis in COVID-19 patients.[14] Elsaie et al. highlighted that dermatological herpes zoster infection may be an alarming sign of a subclinical COVID-19, even in patients with mild or no respiratory symptoms during the pandemic.[15] There have very few isolated case reports on COVID-19 and HZO.

The limitations of this study are its retrospective nature and limited sample size. Furthermore, the availability of fewer centers during lockdown is a factor which cannot be overlooked. However, our study observed apart from the increased number of cases during the COVID-19 pandemic, the presentation can be atypical and unusual which needs to be borne in mind. In addition, this study showed quite a higher percentage of young individuals presenting with the disease. Our observation would recommend further studies before drawing any definitive association.


Herpetic eye disease though not an uncommon condition encountered in clinical practice, the upsurge of viral keratitis in the current pandemic probably requires exclusion of concomitant or recent subclinical COVID-19 even in mild/asymptomatic cases. Furthermore, corneal transplant patients must be educated and made aware of the risk of viral infections in the grafted eye. With the arrival of subsequent waves and with the vaccination drive on, we may expect a greater number of cases of HSV and HZO in the coming time even in young and immunocompetent individuals. However, definitive association cannot be confirmed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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