What is the treatment for herpes simplex (HSV) keratitis near the eye?

Treatment for Herpes Simplex Keratitis Near the Eye

Topical antiviral therapy combined with oral antivirals is the standard treatment for herpes simplex keratitis, with topical ganciclovir 0.15% gel being preferred due to less ocular surface toxicity. 1

Diagnosis and Clinical Presentation

HSV keratitis typically presents with:

• Usually unilateral involvement
• Bulbar conjunctival injection
• Watery discharge
• Mild follicular reaction of conjunctiva
• Possible palpable preauricular lymph node
• Can be bilateral in atopic or immunocompromised patients 2

Treatment Algorithm

1. Epithelial HSV Keratitis (Dendritic/Geographic Ulcers)

• First-line treatment:

  • Topical ganciclovir 0.15% gel 5 times daily until healed, then 3 times daily for 7 days 1
  • PLUS oral antiviral therapy:
    • Acyclovir 400 mg orally 5 times daily for 7-10 days OR
    • Valacyclovir 500 mg twice daily for 7-10 days OR
    • Famciclovir 250 mg twice daily for 7-10 days 1

• Important: Avoid topical corticosteroids in epithelial HSV infections as they can potentiate the infection 1

2. HSV Stromal Keratitis

• Treatment:
  • Oral antiviral therapy (same dosing as above)
  • PLUS topical corticosteroids at minimum effective dose with careful monitoring 1
  • Gradual tapering of steroids based on clinical response

3. HSV Endotheliitis/Uveitis

• Treatment:
  • Oral antiviral therapy (same dosing as above)
  • PLUS topical corticosteroids with careful monitoring 1
  • Consider more frequent follow-up to monitor intraocular pressure

Special Considerations

Immunocompromised Patients

• May require more aggressive treatment:
  • Consider IV acyclovir 5-10 mg/kg every 8 hours for severe cases 3
  • More frequent follow-up (within 48-72 hours) to assess response 1

Prophylaxis for Recurrent Disease

• For patients with frequent recurrences (≥2 episodes per year):
  • Oral acyclovir 400 mg twice daily for 12 months 4
  • This reduces the rate of recurrent ocular HSV disease from 32% to 19% 4
  • Particularly important for patients with history of stromal keratitis 4

Follow-up Protocol

• Initial follow-up within 1 week of treatment initiation 1
• Assess:
  • Symptom improvement
  • Corneal involvement
  • Signs of uveitis
• Subsequent visits should include visual acuity measurement and slit-lamp biomicroscopy 1

Potential Complications and Management

• Corneal scarring: May require keratoplasty if severe visual impairment
• Neurotrophic keratitis: Monitor for dry eye and corneal anesthesia 1
• Secondary bacterial infection: Consider topical antibiotics for eyelid vesicles 1

Prevention of Spread

• Frequent handwashing
• Avoid touching eyes
• Avoid close contact during active infection 1

Treatment Pitfalls to Avoid

1. Using topical corticosteroids without antiviral coverage
2. Discontinuing antivirals too early
3. Failing to recognize and treat associated uveitis
4. Not considering prophylactic therapy for patients with recurrent disease
5. Overlooking the need for ophthalmologist involvement in all cases of herpes zoster ophthalmicus 1

HSV keratitis can lead to significant visual morbidity if not treated promptly and appropriately. The recurrent nature of HSV keratitis underscores the importance of both acute treatment and long-term management strategies to preserve corneal health and maintain optimal visual function 5.