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    Taking on surgery in HSV patients

    Surgeons weigh best candidates, benefits against risks of stimulating recurrence of herpes simplex virus


    HSV ulcer

    If an HSV ulcer persists for more than 2 weeks, Dr. Yeu recommends stopping topical anti-viral treatment and changing to an oral anti-viral prophylaxis, aggressive preservative-free lubrication, a therapeutic bandage over the lens (with particular caution on a neurotrophic ulcer), topical anti-bacterial coverage, self-retaining amniotic membrane, and vitamin C, omega-3 fatty acids, and doxycycline.

    Treatments for keratitis caused by the live virus include valcyclovir 500 to 1,000 mg po TID, acyclovir 400 mg po 5× daily, acyclovir 0.3% ointment 5× daily (not available in the United States), ganciclovir 0.15% gel 5× daily, and trifuridine 1% every 2 hours (with caution because of toxicity), with a potential concomitant epithelial debridement to debulk the viral load.

    HSV epithelial keratitis is a self-limited disease, but treating it as a live viral infection for 21 days can help expedite recovery and limit nerve damage or future immunological disease, Dr. Yeu said.

    For keratitis caused by an immune-mediated reaction, antiviral prophylaxis should be instituted at the lower prophylaxis protocol as aforementioned to prevent re-activation of the active virus from the topical steroid use, according to Dr. Yeu.

    Topical steroids with a very slow taper over months should be used to treat the inflammation, and may be needed once or twice a week indefinitely to maintain remission. Common high-dose topical steroids are needed, such as topical difluprednate 0.05% or prednisolone 1%, every 2 to 3 hours with a very slow taper down to weaker steroids and less frequency.


    Elizabeth Yeu, MD

    P: 757/622-2200     E: [email protected]

    This article was adapted from Dr. Yeu’s presentation during Cornea Day at the 2017 meeting of the American Society of Cataract and Refractive Surgery. Dr. Yeu is a consultant or advisor to Alcon Laboratories, Allergan, ArcScan, Bausch + Lomb/Valeant, BioTissue, iOptics, Johnson & Johnson Vision, LENSAR, Kala Pharmaceuticals, Ocular Science, Ocular Therapeutix, Omeros, Ocusoft, Shire, SightLife Sun, Surgical, TearLab Corp., and TearScience. Her research has been sponsored by Alcon, Allergan, iOptics, Kala, and Topcon. She has ownership interest in ArcScan, Modernizing Medicine, Ocular Science, RPS, SightLife Surgical, and Strathspey Crown.

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