Ophthalmologic Manifestations of Herpes Simplex Keratitis Treatment & Management

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

Medical Care

Since most cases of HSV epithelial keratitis resolve spontaneously within 3 weeks, the rationale for treatment is to minimize stromal damage and scarring. Gentle epithelial debridement may be performed to remove infectious virus and viral antigens that may induce stromal keratitis.

Healing herpes simplex virus dendritic ulcer. Healing herpes simplex virus dendritic ulcer.

Antiviral therapy, topical or oral, is an effective treatment of epithelial herpes infection. Topical ganciclovir ophthalmic gel, approved by the US Food and Drug Administration in 2009, has advantages of low corneal toxicity, less frequent applications, and gel formulation. Trifluridine solution and vidarabine ointment are also effective in treating HSV keratitis. However, epithelial toxicity is a frequent adverse effect, especially with prolonged use. Response to topical therapy usually occurs in 2-5 days, with complete resolution in 2 weeks. Topical therapy should be tapered rapidly after initial response and discontinued after complete healing, generally within 10-14 days. Failure of epithelial healing after 2-3 weeks of antiviral therapy suggests epithelial toxicity, neurotrophic keratopathy, or, rarely, drug-resistant strains of HSV. Vidarabine is often effective against HSV strains that are resistant to trifluridine and acyclovir.

Oral acyclovir (2 g/d) has been reported to be as effective as topical antivirals for infectious epithelial keratitis with the added advantage of no ocular toxicity. The use of systemic acyclovir is increasingly preferred over topical agents in the treatment of HSV keratitis, particularly for patients with preexisting ocular surface disease who are at high risk for toxicity from topical medications, for patients who are immunocompromised, and for pediatric patients. Some physicians prescribe both oral and topical antiviral agents in conjunction when treating infectious HSV keratitis. Newer oral antiviral drugs, such as valacyclovir and famciclovir, further simplify the dosing regimens; however, the optimal dose for ocular disease has not been determined.

Stromal keratitis and endotheliitis are treated with combined corticosteroid and antiviral therapy. Frequent topical steroid therapy is initially prescribed. The dose is subsequently titrated, based on clinical response, to the lowest dosage necessary to control inflammation. Concurrent antiviral medication is used to prevent or limit lytic epithelial keratitis. The optimal dose and the route of administration have not been determined. One common recommendation is to use a topical antiviral agent and a corticosteroid with equal frequency until the steroid dosage can be reduced to a once-daily or less regimen. Alternatively, oral acyclovir in moderate doses (1-2 g/d) achieves therapeutic concentrations in the aqueous humor and may be more effective than topical agents in treating HSV keratouveitis. In necrotizing stromal keratitis, systemic antiviral is also preferred because of corneal toxicity concerns.[7]

Neurotrophic keratopathy is managed with nonpreserved lubricants, eyelid patching, bandage contact lenses, and autologous serum. Potentially epithelial toxic medications should be discontinued. Ulcers that fail to respond to the above measures may heal with tarsorrhaphy. Stromal thinning and perforation may necessitate surgical intervention.

Patients with frequent recurrences of ocular HSV may be placed on a long-term regimen of oral antiviral medication at the prophylactic maintenance dose.

Valacyclovir (500 mg/d) has been shown to be as effective as acyclovir (400 mg bid) in reducing the recurrence of ocular HSV disease.[8]

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Surgical Care

Irregular astigmatism resulting from chronic stromal keratitis may be correctable with rigid gas-permeable contact lenses. Patients with visually significant corneal opacities or corneal perforations may require penetrating keratoplasty for visual rehabilitation. If possible, a small descemetocele or perforation in an inflamed eye may initially be managed with tissue adhesive, bandage contact lens, and/or amniotic membrane transplantation.[9] Corneal transplantation should ideally be deferred until the eye is less inflamed.

The prognosis for a successful graft approaches 80% in eyes without inflammation prior to surgery. Prophylactic oral antiviral therapy following penetrating keratoplasty reduces recurrent ocular HSV disease, reduces graft rejection episodes, and improves graft survival.[10]

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Consultations

Cases refractory to standard management or multiple recurrences after corneal transplant may be referred to a corneal specialist.

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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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