Eyeworld

60 | EYEWORLD | SUMMER 2024 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians Pedram Hamrah, MD Professor of Ophthalmology Vice Chair of Research and Academic Programs Tufts University School of Medicine Boston, Massachusetts Leela Raju, MD Associate Professor Department of Ophthalmology Tulane University New Orleans, Louisiana T here 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 antivi- ral treatment "from the get-go" if you're con- cerned that the patient has a herpes infection. "The best way to treat it is to get them on antivi- rals as soon as possible," she said. As to wheth- er 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 do 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 reduc- es 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. 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 differ- ently 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 suspi- cion," she said. According to Dr. Hamrah, if we see epi- thelial disease, meaning if there are epithelial dendrites (dendritic epithelial keratitis) that are visualized on exam or geographic epithelial ker- atitis, typically you need to start these patients right away on antiviral therapy. In terms of topical treatment, he also men- tioned that it can result in epithelial toxicity. The two topical options currently available are trifluridine (which is more toxic) and a ganci- clovir gel (less toxic but not always covered by insurance and often requires pre-authorization). Oral antiviral medication are usually as effective, he said, and they're typically easier to get covered by insurance, but they may need potential adjustments in the dose depending on the patient's kidney status. "I think generally speaking, most prac- titioners use topical treatments, but others, including myself, prefer oral therapy because of the potential high efficacy, the coverage of insurance, lower chance of toxicity, and better compliance," Dr. Hamrah said. "The frequency of oral therapy is also less than topical drugs." If the patient develops a recurrence, oral treatment is recommended per the Herpetic Eye Disease Study for a year and a half, as this has been shown to decrease the recurrence rate Antiviral treatment for HSV 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

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