This 84-year-old male presented with a four-day history of generalized malaise and painful, bilateral, perioral lesions (Figure 2). One week earlier, he was hospitalized for a bladder infection. Our patient had a long-standing history of type 2 diabetes that was reported to be well controlled with diet and systemic medications. When he presented to our office, he complained of discomfort and blurring in the right eye as well as bilateral severe lip and oral pain.

Figure 2

Best-corrected visual acuities were 20/25 OD and OS. Biomicroscopy revealed bilateral pseudophakia with clear media. Meibomian gland dysfunction with lid margin telangiectasia was present OD and OS. Corneal sensation was reduced OD and OS. Closer evaluation revealed a single dendritic figure on the left cornea just temporal to the visual axis; this lesion stained with lissamine green.

Our initial diagnosis was herpes simplex keratitis (HSK); we prescribed Zirgan (ganciclovir ophthalmic gel 0.15%, Bausch + Lomb) per the manufacturer’s recommendations (one drop five times per day). Over the next week, the dendritic lesion responded well to therapy and cleared with minimal scarring. Corneal sensitivity continued to be reduced.

Herpes labialis (HL), commonly known as cold sores, is caused by a herpes simplex infection of the lips.1 It is the second most common form of lip lesion.2 Like HSK, HL is caused by the type 1 herpes simplex virus. Studies show that herpetic lip lesions may indicate the presence of an underlying systemic disease.

Both herpes simplex and varicella zoster virus latently reside in the trigeminal ganglion in up to 60% of the population.3 Herpes simplex may cause numerous ocular conditions, such as blepharitis, conjunctivitis, epithelial keratitis, stromal keratitis, uveitis, and retinitis. Triggers for reactivation of herpes include fever, exposure to ultraviolet light, trauma, and hormonal changes.3

Diabetes is often associated with impaired cell-mediated immunity and alterations in microvascular structure, conditions that increase the risk for infection and correlate with the duration and severity of diabetes.3 Impaired immunity and compromised microvascular function increase the risk for severe infection in diabetics.

Kaiserman et al evaluated the incidence of herpetic eye disease (HED) in diabetics and the relationship between herpetic eye disease and glycemic control.3 They found that HED is more common in diabetics compared to non-diabetic, age-matched subjects, and diabetic individuals are more likely to have recurrences.3 The age group between 60 and 69 years of age showed the greatest amount of difference between diabetics as compared to non-diabetics.

In the United States, the incidence of diabetes is increasing incrementally.4 The strong association between diabetes and numerous ocular conditions including HED is well established. Patients need to understand that should they experience ocular discomfort, injection, or visual changes including the signs and symptoms of HED, they should report them immediately to their provider.

Dr. Townsend practices in Canyon, TX, and is an adjunct professor at the University of Houston College of Optometry. He is treasurer of the Ocular Surface Society of Optometry and conducts research in ocular surface disease, lens care solutions, and medications. He is also a consultant or speaker for Alcon, Allergan, NovaBay, Shire, TearLab, and Science Based Health. Contact him at


  1. Wang JP, Bowen GN, Zhou S, Cerny A, Zacharia A, Knipe DM, Finberg RW, Kurt-Jones EA. Role of Specific Innate Immune Responses in Herpes Simplex Virus Infection of the Central Nervous System. J Virol. 2012 Feb;86:2273–2281.
  2. Bansal S, Shaikh S, Desai RS, Ahmad I, Puri P, Prasad P, Shirsat P, Gundre D. Spectrum of Lip Lesions in a Tertiary Care Hospital: An Epidemiological Study of 3009 Indian Patients. Indian Dermatol Online J. 2017 Mar-Apr;8:115–119.
  3. Kaiserman I, Kaiserman N, Nakar S, Vinker S. Herpetic eye disease in diabetic patients. Ophthalmology. 2005 Dec;112:2184-8.
  4. Annual Number (in Thousands) of New Cases of Diagnosed Diabetes Among Adults Aged 18-79 Years, United States, 1980-2014. Available at