HSV/VZV

Question 1

Ddx of dendritiform epithelial lesions

Answer 1

HSV
VZV
epithelial regression line
Neurotrophic keratopathy
Soft contact lens wear (thimerosal)
Topical medications (antivirals, beta blockers)
Acanthamoeba epithelial keratitis
Epithelial deposits (iron lines, Fabry disease, tyrosinemia type II, systemic drugs)
Adenovirus (uncommon)
EBV (rare)

Question 2

Do topical corticosteroids treat stromal keratitis? (HEDS study)

Answer 2

Yes, topical corticosteroids significantly decreased stromal inflammation and shortened duration of keratitis

Question 3

Is oral acyclovir (in addition to treatment with trifluridine and corticosteroids) helpful in treating stromal keratitis? (HEDS study)

Answer 3

No, treatment of nonnecrotizing stromal keratitis with oral acyclovir was not beneficial when trifluridine is already being used.

However, acyclovir 400 mg bid or valacyclovir 500 mg daily can be used in lieu of a topical antiviral (which can cause corneal toxicity after 10-14 days).

Question 4

Is treatment-dose oral acyclovir helpful in treating HSV iritis? (HEDS study)

Answer 4

A non statistically significant trend favored the use of oral acyclovir. Anecdotally, many physicians favor its use

Question 5

Does oral acyclovir prevent patients with epithelial keratitis from developing stromal keratitis and iritis?

Answer 5

No, there wasn’t any difference in the development of stromal keratitis and iritis

Question 6

Does acyclovir prophylaxis minimize HSV recurrences?

Answer 6

Yes, recurrent ocular disease was less (approx. 50%) in the group on oral prophylaxis, especially those with recurrent stromal keratitis.

Long-term prophylaxis is recommended for patients with recurrent HSV stromal keratitis.