Treatment of HSV Epithelial Keratitis
For HSV epithelial keratitis, initiate combination therapy with both topical antiviral (ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily) AND oral antiviral (acyclovir 400 mg five times daily, valacyclovir 500 mg 2-3 times daily, OR famciclovir 250 mg twice daily), as oral therapy alone is insufficient to prevent progression of corneal disease. 1, 2
Primary Treatment Approach
Topical Antiviral Therapy
- Ganciclovir 0.15% ophthalmic gel 3-5 times daily is the preferred first-line topical agent due to superior tolerability and less ocular surface toxicity compared to alternatives 1, 3
- Trifluridine 1% solution 5-8 times daily is equally effective but inevitably causes epithelial toxicity if used beyond 2 weeks 1, 4
- Both agents demonstrate equivalent efficacy to acyclovir ointment with healing rates of dendritic ulcers within 7 days in the majority of patients 3, 4
Oral Antiviral Therapy (Mandatory Addition)
- Oral antivirals MUST be added to topical therapy because oral therapy alone fails to prevent progression of HSV blepharoconjunctivitis to infectious epithelial keratitis 1, 2
- Dosing options include: acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily 1
- Case series demonstrate that HSV epithelial keratitis can develop despite therapeutic oral acyclovir monotherapy, but responds when topical antivirals are added 2
Critical Management Principles
Corticosteroid Avoidance
- Topical corticosteroids are absolutely contraindicated in HSV epithelial keratitis as they potentiate viral replication and worsen infection 1
- Corticosteroids are only appropriate for HSV stromal keratitis and must always be combined with prophylactic antiviral coverage 1, 5
Treatment Duration and Monitoring
- Schedule follow-up within 1 week including visual acuity measurement and slit-lamp biomicroscopy 1
- Most dendritic ulcers heal within 6-10 days with appropriate antiviral therapy 3, 4
- Continue topical ganciclovir beyond 2 weeks if needed, as it does not cause the epithelial toxicity associated with prolonged trifluridine use 1, 6
Alternative and Adjunctive Therapies
Debridement Considerations
- Physicochemical debridement (cauterization or curettage) combined with antiviral therapy may accelerate healing compared to antivirals alone 4
- However, antiviral agents must still be used adjunctively to prevent recrudescent epithelial keratitis after debridement 4
Interferon Augmentation
- Topical interferon combined with antiviral therapy significantly speeds epithelial healing at 7 days (OR 13.49) compared to antiviral monotherapy 5, 4
- This benefit diminishes by 14 days, suggesting interferon primarily accelerates rather than improves ultimate healing 4
Common Pitfalls to Avoid
- Never use oral antivirals as monotherapy for active epithelial keratitis—topical therapy is essential for corneal disease control 2
- Avoid trifluridine beyond 2 weeks due to inevitable epithelial toxicity; switch to ganciclovir for extended therapy 1, 6
- Do not prescribe corticosteroids for epithelial disease, even if inflammation appears significant 1
- Consider higher antiviral doses in cases demonstrating apparent resistance to standard therapy 1