52 EyeWorld Asia-Pacific | September 2024 CORNEA ASIA-PACIFIC PERSPECTIVES Vilavun Puangsricharern, MD Faculty of Medicine, Chulalongkorn U., King Chulalongkorn Memorial Hospital, Rama IV Road, Bangkok 10330, Thailand vilavun@hotmail.com I commend Dr. Raju and Dr. Hamrah for their thorough exploration of the potential applications of topical and oral antiviral therapies in managing HSV. HSV poses a significant challenge in ophthalmology due to diagnostic intricacies and treatment complexities. Balancing recurrence prevention with medication side effects, especially the potential toxicity of antiviral drugs, remains a critical concern. The authors’ clinical insights are invaluable in navigating these challenges. HSV keratitis manifests in three primary forms: epithelial, stromal, and endothelial. For epithelial lesions, treatment typically involves either topical antiviral medication or oral Acyclovir (400mg) administered five times daily for 1-2 weeks until lesion healing occurs. Topical steroids have no benefit in this form. In cases of stromal and endothelial involvement, due to ongoing viral replication, combined topical antiviral therapy alongside topical steroids is crucial, aligning with findings from the Herpes Eye Disease Study (HEDS)1-2. In some countries in which topical antivirals are unavailable, oral antiviral Acyclovir (400mg) five times daily can be an effective substitute. Resistant HSV cases are uncommon in my practice, reducing the need for second-line options like valacyclovir, which boasts superior oral bioavailability and less frequent dosing requirements. As highlighted by the authors, neurotrophic keratopathy remains a significant concern post-treatment, necessitating additional interventions such as autologous serum, amniotic membrane transplantation or temporary tarsorrhaphy for persistent epithelial defects. Of particular importance are the authors’ insights on perioperative prevention strategies. In my practice, for patients with a history of HSV keratitis undergoing corneal transplantation, initiating oral antiviral therapy at treatment doses (e.g., acyclovir 400 mg, five times daily) before or immediately after surgery is essential to prevent recurrence, especially when prolonged high-dose steroid use is anticipated. This dosage can be reduced to a prophylactic dose of acyclovir (400 mg) twice daily after 2-4 weeks and discontinued once topical steroid frequency is reduced to less than twice daily. Overall, the complexities of managing HSV keratitis demand nuanced clinical approaches, and the perspectives shared by Dr. Raju and Dr. Hamrah serve as invaluable guidance for optimizing patient care in our practice. Editors’ note: Dr. Vilavun Puangsricharern disclosed no relevant financial interests. Reference: 1. Wilhelmus KR, Gee L, Hauck WW, et al. Herpetic Eye Disease Study. A controlled trial of topical corticosteroids for herpes simplex stromal keratitis. Ophthalmology. 1994;101:1883-1895; discussion 1895-1886. 2. Barron BA, Gee L, Hauck WW, et al. Herpetic Eye Disease Study. A controlled trial of oral acyclovir for herpes simplex stromal keratitis. Ophthalmology. 1994;101:1871–1882. About the Physicians Pedram Hamrah, MD | Professor of Ophthalmology, Vice Chair of Research and Academic Programs, Tufts University School of Medicine, Boston, Massachusetts | pedram.hamrah@tuftsmedicine.org Leela Raju, MD | Associate Professor, Department of Ophthalmology, Tulane University, New Orleans, Louisiana | rajulv25@gmail.com Relevant Disclosures Hamrah: None Raju: None This article originally appeared in the June 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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