Ophthalmologic Manifestations of Herpes Simplex Treatment & Management

  • Author: Robert H Graham, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 20, 2009
 

Medical Care

  • Primary ocular herpes infection with lid vesicles and acute follicular conjunctivitis is a self-limited disease, but treatment is recommended to limit corneal involvement.[11] Treatment options include the following:
    • Trifluridine 1% drops, 9 times a day
    • Vidarabine 3% ointment, 5 times a day
    • Oral acyclovir 400 mg, 5 times a day for 10 days[12] (Oral acyclovir is the preferred treatment in patients unable to tolerate topical medications and with good renal function.)
    • A cycloplegic agent may be added to any of the above regimens for comfort from ciliary spasm.
  • Dendritic, geographic, and marginal corneal ulcers are treated with the following:
    • Debridement of the infected epithelium is performed after instillation of topical anesthetic (4% cocaine or 0.5% proparacaine) into the conjunctival sac. The loose epithelium at the edge of the dendritic figure is wiped away with a sterile cotton-tipped applicator or with the edge of a knife blade or a platinum spatula.
    • Trifluridine 1% drops, 9 times a day; vidarabine 3% ointment, 5 times a day; or 2 g of oral acyclovir once per day
    • Two new antiviral agents, 0.2% cidofovir eye drops and 3% penciclovir ointment, have been effective in the rabbit model in treating herpetic epithelial keratitis and may have a role in humans.
    • Cycloplegic agent
    • Topical steroids may be required after several days of antiviral treatment in patients with marginal ulcers or associated stromal disease to quell the immune response.
    • The attempt to augment or modify the host's immunologic milieu has led some investigators to study the role of cimetidine as an adjunct to standard antiviral therapy. The efficacy of this modality has not been fully established.[13, 14] In vitro studies using both fusion proteins (that block the interaction of T cells with antigen-presenting cells) and basic fibroblastic growth factors have shown a beneficial effect of these as adjunctive treatments in decreasing the incidence of stromal keratitis and iridocyclitis.
  • Stromal keratitis - Prior to the treatment of stromal disease, the status of the epithelium needs to be evaluated. If stromal disease is accompanied with a concomitant epithelial defect, it is treated similar to epithelial keratitis with a topical antiviral agent and a cycloplegic agent until the epithelium has healed. Necrotizing and nonnecrotizing stromal disease without associated epithelial disease or after resolution of the epithelial defect are treated with the following:
    • Topical corticosteroids - The strategy for topical corticosteroid therapy is frequent initial administration (q1-4h) followed by slowly tapering the dose to the lowest effective amount.[15]
    • Topical or oral antivirals are recommended to prevent or limit epithelial disease during the course of treatment with corticosteroids.[16] Many recommendations are available on the frequency of administration of antivirals for prophylaxis. A most commonly used regimen includes administering the drops as often as the recommended therapeutic dose needed to treat epithelial disease. Another regimen includes initiating and tapering the antiviral in the same dosage as the corticosteroid until corticosteroid therapy tapers down to once a day, at which time the topical antiviral is discontinued. The Herpetic Eye Disease Study Group recommended using trifluridine, 4 times a day for 3 weeks and 2 times a day thereafter.
    • Associated elevated intraocular pressure should be treated with timolol and systemic acetazolamide, as necessary.
    • Topical cyclosporin A 2% drops in an uncontrolled study showed efficacy in the treatment of stromal disease without the use of corticosteroids. A role may exist for this medication in those patients unable to use corticosteroids.[17]
    • Indolent stromal ulceration is managed with antiviral and corticosteroid therapy along with a soft contact lens to prevent corneal drying. When melting of the cornea occurs, care must be taken not to stop corticosteroid therapy abruptly, as doing so may lead to rebound inflammation and increase the melting process, thereby resulting in perforation. The anticollagenolytic activity of tetracycline may help retard corneal melting when applied as a topical ointment. Consider the possibility of medication-induced toxicity or an anesthetic cornea when faced with chronic, nonhealing, epithelial defects associated with stromal inflammation. Occasionally, a lateral tarsorrhaphy may be required to treat a nonhealing epithelial defect.
Next

Surgical Care

  • Keratoplasty should be considered for the following:
    • Corneal scarring and opacity that significantly reduces vision
    • Descemetocele formation and imminent perforation from stromal loss
    • Persistent inflammation not responsive to treatment
  • Keratoplasty for corneal scarring secondary to stromal HSV should be performed with caution. The most important factors in determining graft survival are preoperative corneal vascularity and inflammation. Most corneal transplant surgeons wish to have the patient remain without recurrent disease for 6-12 months before considering the procedure. Topical steroids are recommended as an adjunct to keratoplasty, preoperatively, to help control both inflammation and vascularity, and, postoperatively, to prevent rejection and graft failure. Most surgeons use a systemic antiviral agent (eg, acyclovir 400 mg bid) for at least 6-12 months after penetrating keratoplasty[18] .
  • If the cornea perforates, the best management depends on the size and the location of the perforation. Small peripheral perforations may be well treated by cyanoacrylate tissue adhesive. Large or central perforations are best treated with a penetrating keratoplasty. Sealing of a perforated descemetocele with a tissue adhesive and fitting with a soft contact lens often result in reformation of the anterior chamber in preparation for definitive corneal transplantation. Interestingly, because recurrent HSV disease is the result of reactivation of latent virus in the nerve ganglion, the rate of recurrence is not altered after penetrating keratoplasty.
Previous
Proceed to Medication
 
 
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.

Specialty Editor Board

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.

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.

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

  1. Carr DJ, Tomanek L. Herpes simplex virus and the chemokines that mediate the inflammation. Curr Top Microbiol Immunol. 2006;303:47-65. [Medline].

  2. Liesegang TJ, Melton LJ 3rd, Daly PJ, Ilstrup DM. Epidemiology of ocular herpes simplex. Incidence in Rochester, Minn, 1950 through 1982. Arch Ophthalmol. Aug 1989;107(8):1155-9. [Medline].

  3. Saini JS, Agarwala R. Clinical pattern of recurrent herpes simplex keratitis. Indian J Ophthalmol. Mar 1999;47(1):11-4. [Medline].

  4. Holland EJ, Schwartz GS. Classification of herpes simplex virus keratitis. Cornea. Mar 1999;18(2):144-54. [Medline].

  5. Levy J, Lapid-Gortzak R, Klemperer I, Lifshitz T. Herpes simplex virus keratitis after laser in situ keratomileusis. J Refract Surg. Jul-Aug 2005;21(4):400-2. [Medline].

  6. Lu CK, Chen KH, Lee SM, Hsu WM, Lai JY, Li YS. Herpes simplex keratitis following excimer laser application. J Refract Surg. May 2006;22(5):509-11. [Medline].

  7. Kothari MT, Mehta BK, Asher NS, Kothari KJ. Recurrence of bilateral herpes simplex virus keratitis following bimatoprost use. Indian J Ophthalmol. Mar 2006;54(1):47-8. [Medline].

  8. Wilhelmus KR. Diagnosis and management of herpes simplex stromal keratitis. Cornea. 1987;6(4):286-91. [Medline].

  9. Zaher SS, Sandinha T, Roberts F, Ramaesh K. Herpes simplex keratitis misdiagnosed as rheumatoid arthritis-related peripheral ulcerative keratitis. Cornea. Nov 2005;24(8):1015-7. [Medline].

  10. Seitzman GD, Cevallos V, Margolis TP. Rose bengal and lissamine green inhibit detection of herpes simplex virus by PCR. Am J Ophthalmol. Apr 2006;141(4):756-8. [Medline].

  11. Tabbara KF. Treatment of herpetic keratitis. Ophthalmology. Sep 2005;112(9):1640. [Medline].

  12. Miserocchi E, Modorati G, Galli L, Rama P. Efficacy of valacyclovir vs acyclovir for the prevention of recurrent herpes simplex virus eye disease: a pilot study. Am J Ophthalmol. Oct 2007;144(4):547-51. [Medline].

  13. Koelle DM, Ghiasi H. Prospects for developing an effective vaccine against ocular herpes simplex virus infection. Curr Eye Res. Nov 2005;30(11):929-42. [Medline].

  14. Pepose JS, Keadle TL, Morrison LA. Ocular herpes simplex: changing epidemiology, emerging disease patterns, and the potential of vaccine prevention and therapy. Am J Ophthalmol. Mar 2006;141(3):547-557. [Medline].

  15. Wilhelmus KR, Gee L, Hauck WW, et al. Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology. Dec 1994;101(12):1883-95; discussion 1895-6. [Medline].

  16. Kaufman HE, Martola EL, Dohlman CH. Herpes simplex treatment with IDU and corticosteroids. Arch Ophthalmol. 1963;69:468-72.

  17. Rao SN. Treatment of herpes simplex virus stromal keratitis unresponsive to topical prednisolone 1% with topical cyclosporine 0.05%. Am J Ophthalmol. Apr 2006;141(4):771-2. [Medline].

  18. Cobo LM, Coster DJ, Rice NS, Jones BR. Prognosis and management of corneal transplantation for herpetic keratitis. Arch Ophthalmol. Oct 1980;98(10):1755-9. [Medline].

  19. Sozen E, Avunduk AM, Akyol N. Comparison of efficacy of oral valacyclovir and topical acyclovir in the treatment of herpes simplex keratitis: a randomized clinical trial. Chemotherapy. 2006;52(1):29-31. [Medline].

  20. de Rojas Silva MV, Diez-Feijoo E, Javaloy J, Sanchez-Salorio M. Prophylactic perioperative antiviral therapy for LASIK in patients with inactive herpetic keratitis. J Refract Surg. Apr 2006;22(4):404-6. [Medline].

  21. Herpetic Eye Disease Study Group. A controlled trial of oral acyclovir for the prevention of stromal keratitis or iritis in patients with herpes simplex virus epithelial keratitis. The Epithelial Keratitis Trial. Arch Ophthalmol. Jun 1997;115(6):703-12. [Medline].

  22. Herpetic Eye Disease Study Group. A controlled trial of oral acyclovir for iridocyclitis caused by herpes simplex virus. Arch Ophthalmol. Sep 1996;114(9):1065-72. [Medline].

  23. Herpetic Eye Disease Study Group. Acyclovir for the prevention of recurrent herpes simplex virus eye disease. Herpetic Eye Disease Study Group. N Engl J Med. Jul 30 1998;339(5):300-6. [Medline].

  24. Kaiserman I, Kaiserman N, Nakar S, Vinker S. Herpetic eye disease in diabetic patients. Ophthalmology. Dec 2005;112(12):2184-8. [Medline].

  25. Kabra A, Lalitha P, Mahadevan K, Prajna NV, Srinivasan M. Herpes simplex keratitis and visual impairment: a case series. Indian J Ophthalmol. Mar 2006;54(1):23-7. [Medline].

  26. Li H, Zhang J, Kumar A, Zheng M, Atherton SS, Yu FS. Herpes simplex virus 1 infection induces the expression of proinflammatory cytokines, interferons and TLR7 in human corneal epithelial cells. Immunology. Feb 2006;117(2):167-76. [Medline].

  27. Prabriputaloong T, Margolis TP, Lietman TM, Wong IG, Mather R, Gritz DC. Atopic disease and herpes simplex eye disease: a population-based case-control study. Am J Ophthalmol. Nov 2006;142(5):745-9. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.