What is the treatment for numular subepithelial keratitis (nummular subepithelial keratitis) that develops after adenoviral conjunctivitis?

Treatment of Nummular Subepithelial Keratitis After Adenoviral Conjunctivitis

For nummular subepithelial infiltrates developing 10 days after adenoviral conjunctivitis, treatment depends on whether you have visual symptoms: if you have blurring, photophobia, or decreased vision, initiate topical corticosteroids at the minimum effective dose using low-penetration agents like loteprednol or fluorometholone; if asymptomatic, observation alone is sufficient. 1, 2

Treatment Algorithm Based on Symptom Severity

Asymptomatic or Mild Cases

• Observation alone is the appropriate management for patients without visual complaints, as these infiltrates often resolve spontaneously over months 1, 2
• Artificial tears can provide symptomatic relief for any mild irritation 1

Symptomatic Cases (Blurring, Photophobia, Decreased Vision)

• Initiate topical corticosteroids at the minimum effective dose when infiltrates cause visual symptoms 1, 2
• Preferred corticosteroid agents are loteprednol, fluorometholone, or rimexolone because these have poor ocular penetration and lower risk of IOP elevation and cataract formation compared to stronger steroids 1, 2
• Taper slowly to the minimum effective dose once inflammation is controlled, as premature discontinuation commonly leads to recurrence 1, 2

Alternative for Steroid-Resistant or Steroid-Dependent Cases

• Topical cyclosporine (0.05% commercially available or 0.1-2% compounded) is an effective steroid-sparing alternative for patients who cannot taper off corticosteroids or have persistent infiltrates despite treatment 1, 3, 4
• Cyclosporine has been shown to reduce subepithelial infiltrates without the IOP and cataract risks of prolonged steroid use 1, 3, 4
• Topical tacrolimus 0.03% is another effective option for steroid-resistant cases, with studies showing significant improvement in visual acuity and infiltrate scores 3

Critical Monitoring Requirements

All patients on topical corticosteroids require regular follow-up visits that must include: 1, 2

• Interval history and visual acuity measurement
• Intraocular pressure monitoring to detect steroid-induced glaucoma
• Slit-lamp biomicroscopy to assess infiltrate response
• Periodic pupillary dilation to evaluate for cataract formation

Important Caveats and Pitfalls

Timing and Diagnosis

• Subepithelial infiltrates typically occur 1 or more weeks after the onset of adenoviral conjunctivitis, making the 10-day timeframe in this case consistent with expected presentation 1, 2
• Do not confuse these infiltrates with HSV epithelial keratitis, where corticosteroids are absolutely contraindicated and would potentiate viral replication 1, 2, 5

Steroid-Related Concerns

• Animal studies show prolonged viral shedding with corticosteroid use, though human data is lacking on this effect 1
• Avoid premature discontinuation, as recurrence of infiltrates is common when steroids are stopped too quickly 1, 2
• Never use antibiotics in managing this viral condition due to potential adverse effects without benefit 1

Long-Term Considerations

• Patients with history of adenoviral infection have increased recurrence risk after photorefractive keratectomy or LASIK 1, 2

Follow-Up Timing

• Patients not treated with corticosteroids should return if symptoms persist beyond 2-3 weeks for re-evaluation including visual acuity and slit-lamp examination 1, 2
• Patients on corticosteroids require more frequent monitoring based on treatment response and IOP measurements 1, 2
• Patients with severe disease (corneal epithelial ulceration or membranous conjunctivitis) should be re-evaluated within 1 week 1