Management of Herpetic Keratitis
For a patient presenting with conjunctival watery discharge, photosensitivity, and pain suggestive of herpetic keratitis, initiate combination therapy with topical antiviral (preferably ganciclovir 0.15% gel 3-5 times daily) plus oral antiviral therapy (acyclovir 200-400 mg five times daily, valacyclovir 500 mg 2-3 times daily, or famciclovir 250 mg twice daily). 1
First-Line Treatment Approach
Topical Antiviral Selection
- Ganciclovir 0.15% gel is the preferred topical agent due to superior ocular surface tolerability and minimal toxicity with prolonged use 1
- Apply 3-5 times daily until epithelial healing occurs 2, 1
- Alternative: Trifluridine 1% solution 5-8 times daily, but this agent causes inevitable epithelial toxicity if used beyond 2 weeks 2, 1
Oral Antiviral Therapy
The American Academy of Ophthalmology recommends adding oral antivirals to topical therapy: 1
- Acyclovir 200-400 mg five times daily 2, 1
- Valacyclovir 500 mg two to three times daily 2, 1
- Famciclovir 250 mg twice daily 2, 1
Oral antivirals alone may not adequately prevent progression of HSV blepharoconjunctivitis, making the combination with topical therapy essential 2
Critical Management Principles
What to Avoid
- Never use topical corticosteroids without concurrent antiviral coverage in epithelial HSV keratitis, as steroids potentiate HSV infection and can worsen the condition 2, 1
- Avoid prolonged trifluridine use (>2 weeks) due to epithelial toxicity 2, 1
When Steroids Are Indicated
If secondary HSV stromal keratitis develops, topical steroids may be beneficial but must always be used in conjunction with oral antiviral therapy to prevent viral replication 2, 1
Follow-Up Protocol
Schedule follow-up within 1 week of initiating treatment to assess: 2, 1
- Reduced pain and discharge 1
- Decreased corneal infiltrate density 1
- Initial re-epithelialization 1
- Visual acuity measurement 2
- Slit-lamp biomicroscopy 2
Clinical Pearls
Diagnostic Features
The combination of watery discharge, photosensitivity (photophobia), and pain with vesicular lid lesions and dendritic corneal lesions are highly suggestive of herpes simplex 3
Natural History
HSV conjunctivitis is typically self-limited, subsiding within 4-7 days without treatment unless complications develop 3, but treatment should still be initiated promptly upon high suspicion or with concomitant corneal involvement 2
Potential Complications to Monitor
- Epithelial keratitis 3
- Stromal keratitis 3
- Endotheliitis 3
- Corneal scarring, thinning, or perforation 3
- Neurotrophic keratopathy from recurrent infections 1
Long-Term Prophylaxis Considerations
For patients with recurrent disease, lower doses of oral antivirals are considered for long-term prophylaxis against recurrent HSV keratitis 2. After penetrating keratoplasty or in cases of severe recurrences, systemic acyclovir 400 mg twice daily for at least 1 year is recommended 4, 5