Keratitis, Herpes Simplex Virus (158)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

HSV Keratitis Classification and Treatment

***Any suspicion of atypical HSV i.e. non-healing, worsening or increased pain on review:*** THINK ACANTHAMOEBA KERATITIS

  1. Urgent Viral PCR and Acanthamoeba PCR
  2. Urgent review by a Cornea Consultant
  3. Clinical Photograph

Epithelial keratitis (aka Dendritic ulcer)

Signs

  • Dendrites/Geographic ulcer on corneal epithelium
  • Decreased corneal sensation

Basic treatment approach

  • Topical anti-viral eg Ganciclovir 0.15% (Virgan) five times a day for 10-14 days
  • If photophobic, cyclopentolate 1% BD for 3 days
  • If recurrent attacks, consider oral antiviral prophylaxis e.g. Aciclovir 400mg BD for 3 months

Follow up

  • Classic Dendritic Ulcer: review in Cornea PCC in 2 weeks
  • Large Geographic Ulcer: review in Cornea PCC in 1 week

Stromal keratitis WITHOUT ulceration

Signs

  • Multiple/diffuse opacities leading to corneal vascularisation
  • Lipid exudation and corneal scarring
  • Stromal thinning
  • Some AC activity

Basic treatment approach

  • Topical steroid + oral antiviral prophylaxis e.g.Pred forte QDS + Aciclovir 400mg BD
  • Monitor IOP : If >30mmHg, consider Timolol BD

Follow up

  • Review in Cornea PCC in 5-7 days

Stromal keratitis WITH ulceration

Signs

  • Multiple/diffuse opacities leading to corneal vascularisation
  • Lipid exudation and corneal scarring
  • Stromal thinning
  • Some AC activity

Basic treatment approach

  • Topical steroid + topical anti-viral + oral antiviral in therapeutic doses e.g. Pred forte QDS + Ganciclovir 0.15% (Virgan) five times a day for 10-14 days + Aciclovir 400mg five times a day for 1 week, then BD till review
  • Delay topical steroid use until epithelium is intact
  • If photophobic, cyclopentolate 1% BD for 3 day

Follow up

  • Review in Cornea PCC in 5-7 days

Endothelial keratitis (aka Disciform keratitis)

Signs

  • Central/paracentral disc of corneal oedema
  • Descemet’s folds
  • Fine KPs on endothelium
  • Wessely ring

Basic treatment approach

  • Topical steroid + oral antiviral in therapeutic doses e.g. Pred forte QDS + Aciclovir 400mg five times a day for 1 week, then BD till review
  • Monitor IOP : If >30mmHg, consider Timolol BD

Follow up

  • Review in Cornea PCC in 5-7 days

Last reviewed: 04 May 2022

Next review: 25 May 2024

Author(s): Erikitola, Ore

Version: 6

Author Email(s): [email protected]

Co-Author(s): Ramaesh, K., Lockington, D., Anijeet, D., MacDonald, E.

Approved By: Ophthalmology Clinical Governance Forum

Document Id: 158