Treatment of Eye Herpes (Herpes Simplex Keratitis)
For HSV epithelial keratitis, initiate combination therapy with topical ganciclovir 0.15% gel (3-5 times daily) plus oral antiviral therapy (valacyclovir 500 mg 2-3 times daily, acyclovir 400 mg five times daily, or famciclovir 250 mg twice daily)—oral therapy alone is insufficient to control active corneal disease. 1
First-Line Topical Therapy
Ganciclovir 0.15% ophthalmic gel is the preferred topical agent due to superior tolerability and reduced ocular surface toxicity compared to older alternatives like trifluridine, with most dendritic ulcers healing within 7 days 1, 2
Trifluridine 1% solution (5-8 times daily) serves as an alternative topical option if ganciclovir is unavailable, though it carries higher toxicity risk 1, 3
Apply topical therapy 3-5 times daily for ganciclovir gel; the gel formulation provides better bioavailability and patient compliance than ointments 1, 2
Mandatory Oral Antiviral Component
Oral antivirals must be combined with topical therapy—monotherapy with oral agents alone will not adequately treat active epithelial keratitis 1
Choose one oral agent: valacyclovir 500 mg 2-3 times daily, acyclovir 400 mg five times daily, or famciclovir 250 mg twice daily 1
Oral antivirals reduce recurrence risk and provide systemic viral suppression that topical therapy cannot achieve alone 4, 3
Critical Contraindication
Topical corticosteroids are absolutely contraindicated in HSV epithelial keratitis—they potentiate viral replication and worsen the infection, potentially causing geographic ulceration and corneal perforation 1
This contraindication applies even when significant inflammation is present; steroids should only be considered later for stromal disease (not epithelial) and must always be combined with antiviral coverage 5, 3
Follow-Up Protocol
Schedule re-evaluation within 1 week, including visual acuity measurement and slit-lamp biomicroscopy to assess epithelial healing 1
If the epithelial defect persists beyond expected healing time (7-14 days), consider increasing antiviral dosing frequency or investigating apparent resistance 1
Monitor for progression to stromal involvement, which would require modification of the treatment approach 5
Treatment-Resistant Cases
For patients unresponsive to conventional therapy after 4-6 months or those with documented allergies to standard antivirals, oral valganciclovir 900 mg twice daily for 10 days (followed by 900 mg daily for prophylaxis) represents an alternative option 6
Higher antiviral doses should be considered when standard therapy fails before assuming true viral resistance 1
Long-Term Prophylaxis Considerations
After resolution of acute epithelial keratitis, long-term suppressive oral acyclovir therapy reduces the incidence of recurrent HSV keratitis 3
Prophylactic strategies become particularly important given HSV's tendency to establish latent infection in the trigeminal ganglion with periodic reactivation triggered by stress, illness, or immunosuppression 4