This study only considered many hours of exposure throughout a week, without accounting for the intensity of exposure. Less critical problems included the vagaries of measurement of stress and possible errors of recall. Patients may have had difficulty completing recall logs with accuracy 1 week after certain events. The authors conclude that recall bias can overestimate the importance of factors that do not have a causal relationship with herpes simplex virus infection. This is a critical point.
Clinicians often hear patients invoke coincidental factors as a cause for their problems.
Patients may develop herpetic keratitis, and after the fact, blame high stress or a recent infection without justification. This study leaves many questions unanswered. However, it strongly suggests that psychological stress does not trigger recurrences of ocular herpes simplex virus. We cannot be certain of this conclusion because of some problems in the study design, but I now have added confidence to counsel my patients in this regard. I will advise them that we do not know the triggers of their disease, but that stress does not seem to be important.