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EW FEATURE 54 Steroids roundup • August 2017 Tips continued from page 52 the severity of the inflammation and severity of the disease. There are some potential com- plications that steroids can cause. In a younger patient, cataractogenesis is a concern; therefore, if long-term steroids are required, reducing the dosage and utilizing a less potent steroid is recommended. Approx- imately 10–20% of the general population are steroid responders corticosteroid, the longer the interval between subsequent dose re- duction, Dr. de Luise added. "If oral antiviral agents are chosen (in lieu of topical antivirals), they should be maintained in prophylactic doses during corticosteroid treatment." Stromal keratitis pearls Typically, if you're trying to differen- tiate between immune and necro- tizing stromal keratitis, Dr. Jeng said that necrotizing shows signs like melting, broken down epithelium, and cheesy stroma. With immune keratitis, the epithelium is generally intact and it looks less angry, with no associated melting. While it can be challenging to diagnose active immune stromal keratitis, Dr. Mah said that generally, there is edema in the cornea and stromal haze. He added that it's im- portant to look for inflammation in the cornea. Usually, the epithelium is still intact, though not in every case. Dr. de Luise said it's important to have a high index of suspicion that what you're looking at is HSV since it has a large amount of mani- festations. It's important to rule out simplex before thinking of anything else. Each corneal layer can be in- volved separately or sometimes with other layers. Usually, Dr. de Luise added, epithelial disease of herpes simplex is isolated to epithelium and presents as a dendrite. Most herpetic dendrites stain with fluorescein in the bed and lissamine green on the edges. There are two types of stromal herpetic keratitis (both of which have some immune components): herpes simplex stromal keratitis without ulceration and herpes sim- plex stromal keratitis with ulcer- ation. "In patients who have altered immune systems, herpes simplex can manifest as a recurrent stromal condition from a prior epithelial condition," he said. It could come back deeper in the stroma later on after treated. Dr. de Luise suggested looking for swelling and white infiltrates in the cornea. "You might think that the keratitis is a bacterial or fungal infection," he said. "It can be a challenge because with HSV stromal keratitis, microbial cultures are usu- ally negative." HSV management D r. de Luise shared several of the American Academy of Ophthalmology's recommendations for the management of HSV stromal keratitis and HSV disciform keratitis (endotheliitis). Here are suggested treatment regimens in varying scenarios. HSV stromal keratitis without epithelial ulceration Therapeutic dose of topical corticosteroid; prophylactic dose of oral antiviral agent. One strategy would be prednisolone acetate 1%, six to eight times daily tapered over more than 10 weeks; oral acyclovir 400 mg twice a day, or valacyclovir 500 mg once a day, or famciclovir 250 mg twice a day. HSV stromal keratitis with ulceration Limited dose of topical corticosteroid plus therapeutic dose of oral antiviral agent. One strategy would be prednisolone acetate 1% twice daily plus oral acyclovir 400 mg five times daily for 7–10 days, or valacyclovir 500 mg twice daily for 7–10 days, or famciclovir 500 mg twice daily for 7–10 days. The oral antiviral agent is then reduced to prophylactic dose and maintained as long as topical corticosteroids are in use. "As the disease comes under control, prednisolone can be tapered slowly," Dr. de Luise said. HSV endothelial keratitis Therapeutic dose of topical corticosteroid plus therapeutic dose of oral antiviral agent. One strategy would be prednisolone acetate 1%, six times daily; acyclovir 400 mg five times a day, or valacyclovir 500 mg twice a day, or famciclovir 500 mg twice a day. "The oral antiviral agent is reduced to prophylactic dose after 1 week and maintained as long as topical corticosteroids are in use," Dr. de Luise said. "As the disease comes under control, the topical prednisolone acetate can be tapered slowly." The topical corticosteroid does not have to be prednisolone acetate 1% suspension. There are other options, including fluorometholone 0.1% ophthalmic suspension (a weaker steroid), prednisolone sodium phosphate 1% solution, difluprednate 0.05% suspension, rimexolone 1% ophthalmic suspension, or loteprednol etabonate 0.5%. who may have elevated IOP after using topical steroids, Dr. Mah said, so again, reducing the dosage and potency while still managing the condition is critical. If there are concerns about side effects and the patient has been using chronic steroids, Dr. Mah sug- gested fluorometholone or lotepre- dnol. In addition, he suggested off-label use of cyclosporine to try to avoid some of the side effects. In terms of prophylaxis, in HEDS and HEDS 2, topical trifluri- dine was used. Additionally, the use of acyclovir was allowed in HEDS 2. Dr. Mah said he would often choose valacyclovir over acyclovir due to the improved dosage that could increase compliance with therapy, but famciclovir is also an option now that all three are off patent. As far as topical, ganciclovir can be used for prophylaxis as well. Dr. Mah's personal choice is an oral agent, either acyclovir or valacyclo- vir unless there is a contraindication such as poor renal function. Dr. de Luise said that for HSV, it's important to evaluate the cor- neal epithelium before treating. If HSV stromal keratitis is associated with an epithelial defect, it is treated similarly to HSV epithelial kerati- tis, he said, with a topical antiviral agent (topical trifluridine or topical ganciclovir) and a topical cyclople- gic, administered until the epithe- lium has healed, with avoidance of topical corticosteroids. The HEDS group recommend- ed using topical trifluridine four times daily for 3 weeks and 2 times daily thereafter. Topical ganciclovir gel is now available and has lower epithelial toxicity, Dr. de Luise said. "However, because of the risk of toxicity of all topical antivirals on the corneal and conjunctival epithe- lium, oral antivirals are often used preferentially to topical antivirals." Oral antiviral prophylaxis options include oral acyclovir 400 mg twice a day, valacyclovir 500 mg once a day, or famciclovir 250 mg twice a day. Dr. de Luise said that topical or oral antivirals are recommended to prevent or limit epithelial disease during treatment of HSV stromal keratitis with topical corticosteroids. "A common regimen is to admin- ister the topical antiviral in a 1:1 fashion with the topical corticoste- roid as often as the therapeutic dose is needed to treat epithelial disease," he said. The topical corticosteroid and the topical antiviral are tapered together. "Once the topical cortico- steroid is down to one drop a day, the topical antiviral can be discon- tinued," he said. The lower the dose and frequency of topical

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