Eyeworld

EW FEATURE 52 Steroids roundup • August 2017 AT A GLANCE • The treatment choice used for HSV depends on the type of keratitis. Different combinations of steroids and/or antivirals may be used depending on if the patient has a stromal- or epithelial-based keratitis. • The tapering process for steroids must be done carefully over a long period of time. Some patients may have to use the steroids indefinitely, at a very small dose. • In terms of antivirals, oral antivirals are often preferred to topical because they are less toxic. by Ellen Stodola EyeWorld Senior Staff Writer Experts discuss when to use steroids in patients with herpes simplex virus keratitis, which medications to use, and important information on different ways the disease could manifest T reating a patient with her- pes simplex keratitis can be a tricky feat. The physician first needs to identify the specific type of herpetic cor- neal disease, and then choose a plan of action for treatment. Problems can go undiagnosed, be misdiag- nosed, and be recurrent. Bennie Jeng, MD, professor and chair, Department of Ophthalmology and Visual Sciences, University of Mary- land School of Medicine, Baltimore; Francis S. Mah, MD, Scripps Clinic, La Jolla, California; and Vincent de Luise, MD, assistant clinical profes- sor of ophthalmology, Yale Universi- ty School of Medicine, New Haven, Connecticut, discussed the role of topical steroids in herpes simplex virus (HSV) keratitis, which medi- cations are recommended in these cases, what to look for to diagnose these patients, and how to taper or continue to treat the problem. Steroids in HSV Many cases of HSV keratitis are due to an immune response. Most of the time when seeing stromal keratitis, it is an immune-mediated response and not necessarily a necrotizing process, Dr. Jeng said. Additionally, Dr. Jeng said if there is endotheliitis or iritis, this is an immune-mediated response, and steroids are indicated. When talking about epithelial keratitis, when you have dendrite or pseudodendrite appearance, that's a little more controversial, Dr. Jeng said. "Usually an active infectious process would be treated with anti- virals." With HSV, Dr. Jeng said triflu- ridine can be used. His personal belief is that using oral antivirals penetrates the tear film well enough and are not as toxic. But he noted that topical options work as well, as does gentle debridement of the epithelium. "Steroids don't have a role in in- fectious processes," he said, adding that if there is a lot of inflammation in the stroma with the actual epi- thelial infection, you can treat with some steroids. But, Dr. Jeng added, make sure there's adequate antiviral coverage first. "Because if you just use steroids, the virus will prolifer- ate," he said. If you're talking about an im- mune-mediated response, like HSV stromal keratitis, the treatment is steroids, Dr. Jeng said. However, he likes to use antivirals just in case. If patients have stromal disease, prophylaxis with antivirals will de- crease the chance of them having a repeat episode by almost 50%. Every time the patient has an episode, it's potentially vision threatening, he added, so you want to protect against this. Dr. Mah said that there are several different types of disease that HSV can cause in the anterior seg- ment. For example, with epithelial keratitis, he said steroids are rarely, if ever, required, and not needed for most cases. Tips for steroid use in HSV continued on page 54 HSV disciform keratitis HSV stromal keratitis without ulceration Source: Vincent de Luise, MD Generally, he said that stromal keratitis would be the time to use steroids in HSV. He noted the two large studies looking at this use, HEDS and HEDS 2. Both of these used prednisolone acetate 1%, but Dr. Mah noted that multiple steroid options could be used, depending on

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