Ophthalmologic Manifestations of Herpes Simplex Keratitis Medication

  • Author: Jim C Wang, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Nov 18, 2010
 

Medication Summary

Antiviral agents, topical or oral, are prescribed to inhibit viral replication in infected cells. Topical steroids are used to suppress the destructive inflammatory reaction to HSV antigen by the host. Prophylactic antibiotic eye drops are sometimes used concurrently to prevent a secondary bacterial infection while on steroid therapy.

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Antiviral agents

Class Summary

Inhibit HSV replication. In addition to the antiviral medications listed below, cidofovir (Vistide) is a nucleotide analog that selectively inhibits viral DNA production in CMV and other herpes viruses. Has shown success in suppressing HSV only in rabbit models. No commercially available topical formulations yet.

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Trifluridine ophthalmic solution 1% (Viroptic)

 

A structural analog of thymidine; inhibits viral DNA polymerase. Viroptic has better penetration through the cornea and greater efficacy (95% heal rate) than other topical agents. If no response in 7-14 d, consider other treatments.

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Valacyclovir (Valtrex)

 

Prodrug rapidly converted to the active drug acyclovir. Produces greater serum concentration of acyclovir with smaller oral dosing. More expensive than acyclovir but can be as effective with a more convenient dosing regimen.[8] Optimal dose for ocular disease has not been determined.

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Famciclovir (Famvir)

 

Prodrug that when biotransformed into active metabolite, penciclovir, may inhibit viral DNA synthesis/replication. Has been used successfully in the suppression of genital herpes. Its efficacy in HSV keratitis currently is under study.

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Vidarabine (Vira-A)

 

An adenine analog that interferes with early steps of viral DNA synthesis. Vira-A is less effective than trifluridine in treating geographic ulcers, but it is often effective against HSV strains resistant to trifluridine and acyclovir. If no signs of improvement after 7 d or incomplete reepithelialization in 21 d, consider alternative therapy. Severe cases may require longer treatment. After reepithelialization occurs, treat bid for another 7 d to prevent recurrence.

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Acyclovir (Zovirax)

 

A synthetic guanosine analog that requires activation by viral thymidine kinase. The activated acyclovir triphosphate, concentrated 50-100 times in HSV-infected cells, suppresses viral replication by preferentially inhibiting viral DNA polymerase, serving as a DNA chain terminator and inducing irreversible binding between polymerase enzyme and the interrupted DNA chain. Potent inhibition of viral growth with minimal toxicity to uninfected epithelial cells. Oral acyclovir at a dose of 2 g/d for 10 d has been reported to be as effective as topical agents for epithelial keratitis with the advantage of no ocular toxicity. Topical acyclovir formulation (3% ointment), which is equal in efficacy to trifluridine but less toxic, is not commercially available in the United States.

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Ganciclovir ophthalmic gel 0.15% (Zirgan)

 

Acyclic nucleoside analogue of 2'deoxyguanasine. Phosphorylates first to monophosphate form by viral-encoded protein kinase homologue, then to diphosphate and triphosphate forms by cellular kinases, allowing for greater concentration of ganciclovir in virus-infected cells, possibly due to preferential phosphorylation of ganciclovir in virus-infected cells. Thought to inhibit HSV replication by competitive inhibition of viral DNA polymerases and by incorporating itself into viral DNA, causing termination of viral DNA elongation. Like acyclovir, ganciclovir is virostatic and only exerts its effect on replicating virus.

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Contributor Information and Disclosures
Author

Jim C Wang, MD  Vitreo-Retinal and Cornea/Anterior Segment Subspecialist, Department of Ophthalmology, Kaiser Permanente Fontana Medical Center

Jim C Wang, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and American Society of Retina Specialists

Disclosure: Nothing to disclose.

Coauthor(s)

David C Ritterband, MD  Assistant Director of Cornea and External Disease, Clinical Associate Professor, Department of Ophthalmology, New York Eye and Ear Infirmary, New York Medical College

David C Ritterband, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Jack L Wilson, PhD  Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee at Memphis

Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

References

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Herpes simplex virus dendritic ulcer stained with rose bengal.
Herpes simplex virus dendritic ulcer stained with fluorescein.
Large paracentral herpes simplex virus dendritic ulcer.
Recurrent herpes simplex virus dendritic ulcer with an adjacent stromal scar.
Healing herpes simplex virus dendritic ulcer.
Herpes simplex virus geographic ulcer.
Neurotrophic keratopathy.
Large neurotrophic ulcer.
Active immune stromal keratitis.
Inactive immune stromal keratitis.
Disciform endotheliitis with secondary stromal ulceration.
 
 
 
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