48 EyeWorld Asia-Pacific | September 2024 CORNEA by Ellen Stodola, Editorial Co-Director Antiviral Treatment For HSV There are several options for antiviral treatments for HSV. Leela Raju, MD, and Pedram Hamrah, MD, discussed both topical and oral options, when to get patients treated, how quickly the treatment works, and how this can impact the patient in the future. Dr. Raju said you should incorporate antiviral treatment “from the get-go” if you’re concerned that the patient has a herpes infection. “The best way to treat it is to get them on antiviral as soon as possible,” she said. As to whether you choose topical or oral treatment, Dr. Raju said there are differing opinions on this. Some of the topical options can cause toxicity. “What I find works best for me is that generally trifluridine has been recommended nine times a day, but I do not do it that often. I usually recommend that patients apply it five times a day, and I taper much faster than prescribed because the idea is to stop the viral replication, which it can do at a lower dose and hopefully you’ll avoid corneal toxicity,” she said. A lot of people find oral antivirals easier because you don’t have to worry about that. “There is concern about the kidney function when you put them on oral antivirals. You want to make sure you won’t be exacerbating any levels of poor kidney function, but luckily, it’s a very well-tolerated medication,” she said. In addition, there needs to be lubrication of the eye, Dr. Raju said. “We know that this often leads to neurotrophic keratopathy in many patients, so they’re not going to notice how dry their eyes are. People often forget that a great first line for epithelial keratitis is removing the dendrite. Peeling the dendrite off actually reduces the viral shedding.” When discussing if she would choose topical over oral or vice versa in certain scenarios, Dr. Raju said it’s more about if you think the patient can’t handle the oral medication. They could have trouble swallowing pills or the frequency could be a problem. If you’re talking about a drop vs. a pill five times a day, sometimes patients want that option, but this is only for epithelial keratitis. With stromal keratitis, you need oral delivery. The other problem with herpetic keratitis Dr. Raju said is that it often presents so differently in different patients that it may not look like what you’re used to seeing or what’s in a book. “You have to have a high level of suspicion,” she said. According to Dr. Hamrah, if we see epithelial disease, meaning if there are epithelial dendrites (dendritic This is a photo of a 33-year-old patient who had been treated with oral antivirals only, and still had multiple recurrences; the last one caused the scar pictured. Dr. Raju started the patient on topical steroids as well as continued the oral prophylaxis. Source: Leela Raju, MD
RkJQdWJsaXNoZXIy Njk2NTg0