Treatment of Herpes Simplex Virus (HSV) Conjunctivitis
For HSV conjunctivitis, initiate combination therapy with both topical antivirals (ganciclovir 0.15% gel 3-5 times daily OR trifluridine 1% solution 5-8 times daily) AND oral antivirals (acyclovir 200-400 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 disease progression. 1, 2
Treatment Algorithm
First-Line Therapy: Combination Approach
Topical antiviral options:
Oral antiviral options (choose one):
Critical Rationale for Combination Therapy
The American Academy of Ophthalmology guidelines explicitly state that oral antivirals alone may not adequately prevent progression of HSV blepharoconjunctivitis, and the addition of topical antiviral treatment has proven effective. 1 This is supported by clinical evidence showing HSV infectious epithelial keratitis developing despite therapeutic oral acyclovir, which then responded to topical antivirals. 2
Treatment Duration and Monitoring
- Follow-up within 1 week including interval history, visual acuity measurement, and slit-lamp biomicroscopy 1
- Topical trifluridine should not exceed 2 weeks due to inevitable epithelial toxicity 1
- Ganciclovir gel is better tolerated with lower cellular toxicity compared to earlier generation antivirals 3, 5
Critical Contraindications and Pitfalls
Avoid Topical Corticosteroids
Topical corticosteroids potentiate HSV epithelial infections and must be avoided. 1 This is a critical error that can lead to severe disease progression.
Special Populations Requiring Urgent Action
- Neonates require immediate consultation with pediatrician or primary care physician, as systemic HSV infection is life-threatening 1
- Immunocompromised patients may need more aggressive treatment with higher antiviral doses 6
Resistant Cases
For cases demonstrating apparent resistance to standard therapy:
- Consider higher doses of oral antivirals based on anecdotal experience 1
- Increase oral acyclovir to 800 mg five times daily if poor response to standard dosing 7
- Verify HSV etiology with cultures and consider susceptibility testing if available 7
Long-Term Management
- Lower doses of oral antivirals are used for long-term prophylaxis against recurrent HSV conjunctivitis and keratitis 1
- Patients with chronic sequelae may require prolonged treatment and/or long-term prophylaxis 6
Key Clinical Pearls
- HSV conjunctivitis is self-limited but treatment is typically initiated upon high suspicion or with concomitant corneal involvement 1
- Ganciclovir gel has become standard of care in many countries due to superior tolerability profile while maintaining equivalent efficacy to acyclovir ointment 3, 5
- The combination approach addresses the documented inadequacy of oral monotherapy in preventing ocular HSV progression 2