eMedicine Specialties > Ophthalmology > Cornea

Herpes Simplex: Follow-up

Author: Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Coauthor(s): Kerry Assil, MD, Medical Director and CEO, The Sinskey Eye Institute
Contributor Information and Disclosures

Updated: Feb 20, 2009

Follow-up

Further Outpatient Care

  • The major difficulties in treating herpetic keratitis are related to the tendency for recurrences and to the management of stromal disease. In its latent form, HSV can be present in the cells of the cornea and in the central connections of the trigeminal nerve, particularly in the trigeminal ganglion. Disturbance of the nerve results in reactivation of the virus and its subsequent passage centrifugally along the nerve, with shedding from the nerve endings. Lesions tend to occur when the balance between latency and host defenses is disturbed, such as during febrile illnesses, during menses, or on exposure to sunlight. Once trigger factors are identified, they need to be avoided. Using 400 mg of acyclovir once or twice a day as prophylaxis can reduce the incidence of recurrence. This is recommended for patients with recurrent stromal disease or more than 2 episodes of epithelial disease per year.

Inpatient & Outpatient Medications

  • Acyclovir (400 mg bid) as prophylaxis to prevent recurrence

Deterrence/Prevention

  • Acyclovir (400 mg qd or bid) as prophylaxis to prevent recurrence

Complications

  • Even with proper treatment, corneal scarring can occur, and, if it is central, visual acuity can be lost.

Prognosis

  • The prognosis is generally favorable with aggressive treatment.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Early diagnosis and treatment can help shorten the visual therapy.

Special Concerns

  • The major problem related to therapy is the difficulty in achieving a precise debridement that does not damage the Bowman layer. Some forms of debridement are particularly injurious. The use of sharp instruments, cryotherapy, or strong chemicals (eg, phenol, iodine) should be avoided because they can cause unnecessary damage. Adequate debridement usually can be achieved by brushing the epithelial lesions with a cotton-tipped applicator, a technique that is not only convenient but effective in that epithelial healing is rapid (usually within 24 h) with resultant early disappearance of pain and discomfort. Any tendency for recurrent lesions to form in the early period after healing can be overcome by using a topical antiviral for 7-10 days after debridement.
  • Topical corticosteroids are effective in suppressing the inflammatory response of herpetic keratitis. However, their inappropriate use may result in severe epithelial disease or stromal necrosis, corneal perforation, increased tendency toward recurrence, secondary microbial infections, elevation of the intraocular pressure, and lenticular changes. Patients requiring topical corticosteroids for suppression of the inflammatory response usually require the drug for a period of months, and withdrawal often is complicated by recurrence of inflammation. The immunosuppressive complications of steroid administration (eg, recurrent epithelial disease) largely can be avoided by the concurrent administration of antiviral therapy. Patient cooperation is a prerequisite for the safe administration of corticosteroids in herpetic keratitis. An extremely slow corticosteroid taper typically is required.
  • All topical antiviral medications available for clinical use in the United States are toxic, with signs of toxicity being similar for all such drugs. Punctate epithelial keratopathy, limbal follicles, a follicular conjunctival response, ptosis, punctal stenosis, and contact dermatitis can occur at any time after 10-14 days of therapy. In mild cases of antiviral toxicity, epithelial changes may be the only manifestation. The toxic potential of antiviral agents always should be considered in patients who heal poorly, because these agents are inhibitors of cell division.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Anisha Judge, MD, to the development and writing of this article.



More on Herpes Simplex

Overview: Herpes Simplex
Differential Diagnoses & Workup: Herpes Simplex
Treatment & Medication: Herpes Simplex
Follow-up: Herpes Simplex
References
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Further Reading

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Keywords

herpes simplex, herpes simplex virus, HSV, keratitis, corneal ulcer, dendrite, conjunctivitis

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Contributor Information and Disclosures

Author

Robert H Graham, MD, Senior Associate Consultant, Department of Ophthalmology, Mayo Clinic, Scottsdale, Arizona
Robert H Graham, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Arizona Ophthalmological Society
Disclosure: WebMD/eMedicine Salary Employment

Coauthor(s)

Kerry Assil, MD, Medical Director and CEO, The Sinskey Eye Institute
Kerry Assil, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Association for Research in Vision and Ophthalmology, and Contact Lens Association of Ophthalmologists
Disclosure: Nothing to disclose.

Medical Editor

Kilbourn Gordon III, MD, FACEP, Urgent Care Physician
Kilbourn Gordon III, MD, FACEP is a member of the following medical societies: American Academy of Ophthalmology and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman 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

CME Editor

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.

 
 
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