Eyeworld

Cornea Looking at how long to keep patients on oral antivi- ral therapy after a first and second episode of HSV epithelial keratitis, the highest percent of respondents noted 2 weeks (27%) or 1 month (23%) after the first episode. I think this is exactly what we would expect. Though I think a lot of clinicians may still rely on topi- cal antivirals for single episodes. The assumption is that everyone uses oral antivi- ral. But I think the theme is you probably would use antivirals for a first episode for about 10–14 days, and it looks like at least 40% of the respondents do. You see the natural trend of once you have the second episode, patients are going to be on that anti- viral for a long time. I think most doctors would say 6 months or more. We see the growing trend for longer and longer use, and that's exactly where I land. A similar question asked about oral antiviral thera- py for HSV stromal keratitis after the first and second episodes; respondents indicated 1 month (20%), and also 2 weeks and 3 months, as the most common. After the second episode, 1 year to lifelong treatment was favored. It's similar for the first episode of stromal keratitis. I think the shift is more to the left on that scale, where you're going to use antivirals longer. It's double the number of clinicians who would use lifelong antiviral versus for epithelial disease. Stromal disease is just a more visually impactful. Looking at the second recurrency, the trend ramps up; more than 50% of clinicians are going to be at 6 months, a year, or even lifelong. If you have a patient with HSV stromal keratitis, with ulceration and HSV iritis, this is the worst patient that can walk into your office. The majority of respon- dents (69%) wait until the corneal epithelial defect has resolved before starting topical steroids. Additionally, 22% will start topical steroid drops immediately, and 9% do not use topical steroid drops for this. I think most clinicians are going to at least want to see significant clinical improvement before adding a steroid. Most of them will wait until the defect has resolved before starting steroids. In that middle range are those clinicians who would at least like to see some improvement but are willing to start treatment for stromal disease, even when there is some epithelial involvement. Then you've got the very conservative group, which is only about 9%, where if they have an epithelial defect, they are not going to give steroids with ulcerative keratitis. I think a lot of that's based on fear that the steroids are going to worsen an infection, and in stromal keratitis, you do need steroids. I think that category is the one where most people are going to be using an oral antiviral. You get a bit of the best of both worlds; you have the antiviral on board as you begin the steroid. —Brandon Ayres, MD ASCRS Cornea Clinical Committee Chair n=666 If you have a patient with HSV stromal keratitis with ulceration and HSV iritis, at what point do you prescribe topical steroid drops? I wait until the corneal epithelial defect has resolved before starting topical steroids 69% 22% I start topical steroid drops immediately, even with the presence of a corneal epithelial defect 9% I do not prescribe topical steroid drops for HSV stromal keratitis with ulceration and HSV iritis 13% 6% 1 week 27% 9% 2 weeks 23% 18% 1 month 13% 15% 3 months 10% 15% 6 months 8% 18% 1 year 6% 19% Lifelong First episode Second episode How long do you keep patients on oral antiviral therapy after a first and second episode of HSV epithelial keratitis? n=819 8% 3% 1 week 16% 7% 2 weeks 20% 12% 1 month 18% 16% 3 months 13% 14% 6 months 11% 20% 1 year 14% 28% Lifelong First episode Second episode How long do you keep patients on oral antiviral therapy after a first and second episode of HSV stromal keratitis? n=819

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