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Lid lesions and conjunctivitis can often be managed palliatively. Cool compresses and artificial tears are helpful, and oral agents can be used. Epithelial lesions respond extremely well to topical antiviral therapy. Mainstay of treatment is Viroptic (triflurodine), a topical drop that is extremely effective against Herpes simplex virus but very toxic to the cornea. It is also very expensive: 7.5 ml costs from $100 to $125--even generic! Viroptic is used every 2 to 3 hours while awake with an ideal maximum of around 9 drops per day (toxicity). Debridement of corneal epithelium in geographic cases may rarely be helpful. Medicamentosa is very common with secondary keratitis, but the drug is almost universally effective in treating the infection.
Vidarabine (Vira-A) ointment is currently off of the market once again and is not being manufactured. Idoxuradine (IDU) is no longer made. Topical Acyclovir ointment is used in other parts of the world and is very effective, but it is not available in the US. Viroptic is used unless toxicity prevents it or it is unavailable (frequent raw material shortages). Treatment continues until epithelial defect is resolved then gets decreased to QID for several more days. (Personal preference is about one week.)
Steroids hasten the progression of and worsen epithelial disease. They are, however, critical in the management of stromal lesions to prevent scarring. Treat stromal inflammation aggressively with steroids while concomitantly using topical antiviral therapy. This manages concurrent epithelial disease or helps prevent its occurrence.
Neurotrophic keratitis is managed based upon its level of severity. Mild cases can be handled with artificial tears and/or punctal occlusion. More severe cases may require patching or a bandage contact lens. Tarsorraphy is a last resort. Tissue adhesives can be used in cases of stromal thinning or melting.
Oral agents including acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are rarely helpful in the management of acute corneal disease. They may be useful with recalcitrant limbal dendrites. They are used as prophylaxis to help reduce the rate of recurrences. This means of treatment decreases reactivation rate of stromal disease but not epithelial.
Oral agents dosing:
--Zovirax (200,400,800) : 200mg QID
--Also available in a pediatric suspension
--Famvir (125,250,500) : 500mg TID
--Valtrex (500) : 1000mg TID
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