Herpes Simplex Treatment with IDU and CorticosteroidsTopical administration of medrysone 1. Treatment herps this drug resulted in a keratitis that was more severe in its clinical characteristics and ran a more prolonged course than the disease observed in control animals. A ten-day course of therapy also resulted in a prolongation of the period during which virus could be cultured from the eye. The dbol prevent water retention effects produced by medrysone 1. Takahashi, Herpes simplex oculare corticosteroidi ; Howard M. Herpes simplex oculare corticosteroidi in to access your subscriptions Sign in to your personal account. Create a free personal account to download free article PDFs, sign up for alerts, and more.
Herpes Simplex Virus (HSV) Keratitis Medication: Antiviral agents
Many challenges surround HSV ocular disease—from establishing the diagnosis to preventing recurrence. Three experts dispel the myths and share tips to identify, classify, and tackle the disease. Tuli, associate professor of ophthalmology, director of the cornea and external diseases service, and residency program director at the University of Florida in Gainesville.
Indeed, HSV can appear similar to many other eye conditions—herpes zoster, Acanthamoeba infection, topical medication toxicity, and healing abrasions, to name just a few. Each year, about 50, new and recurring cases of ocular HSV predominantly type 1 are diagnosed in the United States.
Posterior segment disease, such as acute retinal necrosis, can occur but is uncommon. The recurrence rate of HSV eye disease after an initial episode is approximately 27 percent at one year, 50 percent at five years, and 63 percent at 20 years.
The risk increases with the number of recurrences. By and large, primary herpes is pediatric. Initially, the virus enters the eye and travels to the trigeminal ganglion, where it replicates and becomes latent. When it later travels back to the cornea, HSV causes episodic ocular disease, but it remains in the trigeminal ganglion for life.
Proven triggers include UV light, fever, and refractive surgery, but almost every one of Dr. Broadly speaking, HSV keratitis can be divided into two types: Making the distinction is paramount because the treatment approaches are very different. Within the epithelial and stromal groups, HSV can manifest in various ways, and a hodgepodge of terms have been used to describe each presentation.
Chodosh, who is spearheading a simplified, anatomic classification system that he hopes will get everyone speaking the same language Table 1. Chodosh teaches his residents to make an anatomic diagnosis before doing anything else.
Then you can work through those, based on the history, appearance, time course, risk factors, and associated findings. In epithelial disease, the classic HSV findings are dendriform lesions dichotomous branching with terminal bulbs. If there is no ulceration, stromal disease tends to run a relatively indolent course. When ulceration is present, perforation is a risk.
When the presentation is not dendritic, testing for corneal sensation may help to identify HSV. This leads to hyposensitivity. Clinicians often ask Dr. We routinely test five locations: We also test sensation over the lesion itself.
When else to suspect herpes. Certain things should raise your index of suspicion. And always suspect herpes in patients with a history of herpes. However, typical conjunctivitis is caused by viruses such as adenovirus, which is almost always bilateral.
HSV is almost always unilateral. Among the population with unilateral conjunctivitis, about 25 percent have herpes, according to Dr. If the culture is positive for herpes, Dr. Tuli recommends treatment with oral acyclovir for two weeks. More important than yielding a treatment regimen, positive HSV cultures identify people who are at risk for recurrent disease. Tuli suggests putting a sample on a slide, just as you would for a Pap smear, and sending it for a standard Pap test.
HSV epithelial keratitis live virus should be treated with topical or oral antivirals but not with steroids. HSV stromal disease little, if any, virus requires steroids with oral never topical antivirals as prophylaxis.
Surgery may be needed to correct the damage caused by HSV, but it should be performed only when the eye is quiet. Either way, it takes about seven days to heal, he said. Margolis and Chodosh prefer oral monotherapy. They question whether the systemic drug can get into the eye and do as good a job as a topical agent. Tuli added a cautionary note on the use of topical antivirals: This is toxic to the eye and results in scarring. Over 95 percent of dendritic lesions are cured in under two weeks.
Either way, after two weeks, stop topical antivirals! Another option is corneal epithelial debridement. Treatment time is about 2. Some people will debride and use a topical agent; some will debride and use an oral agent. If the keratitis is close to the visual axis and the patient has had more than one episode, Dr.
Tuli also uses oral antivirals long term to prevent recurrence. Stromal disease is where the most damage is done. The primary treatment for stromal disease is topical steroids in conjunction with prophylactic oral antivirals. Topical antivirals should never be used long term for prophylaxis because they can cause corneal toxicity, but orals can be used safely for substantial periods of time.
Margolis likes to start the oral antiviral a couple of days before the steroid, he has initiated them simultaneously in cases of stromal disease without ulceration. Endotheliitis is active virus in the anterior chamber of the eye. Margolis, who treats these patients with oral antivirals because he knows these drugs will get into the anterior chamber. When to use them. Other than that, topical corticosteroids prednisolone acetate 1 percent or prednisolone phosphate 1 percent are essential for treating HSV stromal keratitis.
These agents control inflammation and minimize damage to the eye. You rarely need to use a topical steroid more than four times a day to get stromal disease under control, according to Dr. S-l-o-w-l-y taper the dose. Once inflammation is under control, the goal is to find the minimal effective dose that will keep the eye quiet.
Patients have to get off steroids. Topical steroids should be maintained for as long as necessary. More than 50 percent of her patients remain on microdoses for life.
These patients are also on chronic oral antivirals. After the patient completes a treatment regimen of oral or topical antivirals for seven to 10 days, oral antivirals then serve solely as prophylaxis. Prophylaxis must be discontinued after one year.
Because HEDS demonstrated the effectiveness of prophylaxis for one year, 4 many believe that it cannot be used for more than a year. Oral acyclovir reduces the severity of stromal disease and the frequency of recurrence for as long as it is maintained. Prophylaxis requires at least mg of acyclovir two or more times a day Table 2. When to use it. Compliance is excellent because they know the consequences of going off the antiviral.
Any patient who is undergoing eye surgery and has a history of HSV should start prophylaxis a few days before surgery and continue it at least until the inflammation has subsided, advised Dr. TULI, MD Associate professor of ophthalmology, director of the cornea and external diseases service, and residency program director, University of Florida, Gainesville. The slide show above presents various manifestations of HSV keratitis, a sight-threatening, but sometimes difficult to diagnose, condition.
Uveitis Guidelines—Immunomodulatory Therapy Letters. Richard Mills' Opinions, Demystifying the Ocular Herpes Simplex Virus. Gabrielle Weiner, Contributing Writer. Geographic ulcer in epithelial keratitis. Dendritic presentation of epithelial keratitis. Stromal keratitis with ulceration necrotizing keratitis.
Stromal keratitis without ulceration interstitial keratitis. Endothelial keratitis disciform keratitis. Log In Forgot password Forgot email. There are no comments available. Most Viewed content is not available. Education Guidelines News Multimedia. Thank you Your feedback has been sent.