Treatment of Herpetic Keratitis

First-Line Treatment Options

The American Academy of Ophthalmology recommends a combination of topical antiviral agents, such as ganciclovir 0.15% gel three to five times daily or trifluridine 1% solution five to eight times daily, along with oral antiviral therapy, such as acyclovir 200-400 mg five times daily, valacyclovir 500 mg two to three times daily, or famciclovir 250 mg twice daily, for the treatment of herpetic keratitis 1
Ganciclovir 0.15% gel is preferred due to better ocular surface tolerability and less toxicity with prolonged use 1
Trifluridine 1% solution is effective but causes epithelial toxicity if used longer than 2 weeks 1

For epithelial herpetic keratitis, the American Academy of Ophthalmology recommends starting with topical antiviral therapy, preferably ganciclovir 0.15% gel, 3-5 times daily, and considering adding oral antiviral therapy in moderate to severe cases 1
For HSV stromal keratitis, a combination of oral antiviral therapy and topical corticosteroids at minimum effective dose is recommended, with oral antivirals essential when using topical steroids to prevent viral replication 1, 2
Topical corticosteroids should be tapered slowly once inflammation is controlled, and corticosteroids with poor ocular penetration, such as fluorometholone or loteprednol, should be used to minimize IOP elevation and cataract formation 1

The American Academy of Ophthalmology recommends scheduling follow-up within 1 week of initiating treatment, and assessing for reduced pain and discharge, decreased corneal infiltrate density, initial re-epithelialization, and cessation of progressive corneal thinning 1, 3
Regular monitoring of IOP and pupillary dilation is recommended if using topical corticosteroids 1

Persistent epithelial defects may require adjunctive therapies, such as lubrication, bandage contact lens, or amniotic membrane 3
Secondary bacterial infection should be treated with appropriate antibiotics based on culture results 4
Neurotrophic keratopathy may develop due to corneal nerve damage from recurrent HSV infections 5

Using topical corticosteroids without antiviral coverage in epithelial HSV keratitis can potentiate the infection 1
Tapering topical antibiotics below therapeutic dosing may increase the risk of resistance 4
Prolonged use of trifluridine beyond 2 weeks can cause epithelial toxicity 1
Failure to distinguish between medication toxicity and worsening infection can lead to inadequate treatment 3