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past four days (Fig. 1, Fig. 2). She is currently under chronic care for her advanced dry eye syndrome. She uses preservative-free (PF) artificial tears inconsistently for her ocular surface disease.
Fig. 1 While it is obvious that this woman has severe dry eyes, as evidenced by rose bengal staining, her chief complaint was that her right eye was hurting.
Fig. 2 Upon more careful inspection of her right cornea, it can be seen that she has classic herpes epithelial keratitis
2+ conjunctival injection OD; 1+ OS 2+ rose bengal staining OU
Epithelial herpes simplex keratitis (HSK) OD Bilateral keratoconjunctivitis sicca
• • •
Trifluridine (Viroptic) ophthalmic solution 1 gt. OD q2h. x 4 days Unit dose TheraTears Liquid Gel q.i.d. OU Return to clinic in 4 days
concurrent use of artificial tears is useful when treating HSK.d.i. OU Re-evaluate patient in one month to assess ocular surface status. decide whether to modify topical therapy and/or insert punctal plugs Comments: This rather straightforward diagnosis is complicated by the underlying dry eyes.i. Because this patient had preexisting keratoconjunctival epithelial tissue compromise.i.d. At that time.d. it was important to use a more viscous . OU Return to clinic in 4 more days Second Follow-Up Visit Subjective • Both eyes feel "much better" Objective • • • Corneal epithelium renormalized OD BUT: 6 to 7 seconds OU Modest reduction in rose bengal staining pattern Assessment • • Resolved HSK Chronic keratoconjunctivitis sicca with chronic ocular surface disease Plan • • • Discontinue trifluridine Continue unit dose TheraTears Liquid Gel q. Since all topically applied antivirals are potentially toxic to the cornea.First Follow-Up Visit Subjective • OD feels much better Objective • Herpetic lesions 80% improved Assessment • HSK responding nicely to antiviral therapy Plan • • • Decrease trifluridine to q. OD x 4 days Continue unit doseTheraTears Liquid Gel q.
such as TheraTears Liquid Gel hourly. superficial punctate keratitis-like lesions.. stress. end-bulbs versus bifurcations and branches without end-bulbs. once the drug is dispensed to a patient. it does not have to be kept refrigerated. Typical dendritic keratitis • • • • • • • • • • Hypoesthesia is experienced in the affected cornea (Q-tip sensitivity test can occasionally be helpful) Pain is usually not severe because of subdued corneal afferent neuronal sensitivity (via the nasociliary pathway) Fluorescein tends to stain the central ulcer bed. Following the first secondary (epithelial) infection. (Note: While trifluridine is properly stored under refrigeration. Men have a slightly greater tendency to recurrences than women The genome.) Factors that complicate and prolong the natural history and clinical management: o infectious foci near the limbus o prior treatment with corticosteroids o delay in seeking care by the patient o underlying stromal inflammation . etc.) Clinical Observations of Epithelial Disease • Cornea may initially show coarse. sunburn. Timely. whereas rose bengal or lissamine green tends to stain the leading edges of viral proliferation bout 90% of adults harbor this neurotrophic virus following a usually asymptomatic primary infection as a child Latent virus resides in Gasserian (trigeminal) ganglion Two common types: I and II.product. Advise the patient that there is a 25% to 50% chance of HSK recurrence and to return promptly if the symptoms reappear. 3). trauma. menstruation. or any immuno-compromising condition. of the various herpes strains is thought to direct the clinical behavior and clinical expression of the infecting virus (i. or less commonly. a geographic lesion Fig 3. which usually coalesce to form linear or dendriform appearance (Fig. punctate. there is a 25% chance of a recurrence.e. or DNA uniqueness. serious versus mild pathogenicity. the chance of subsequent recurrences increases to about 40% to 45%. steroidal exacerbation of disease versus nonsteroidal exacerbation. of which type II is usually genital Opportunistic virus reactivation risk factors: fever. prostaglandin-eyedrops. corticosteroid use. causing stromal disease versus nonstromal involvement. proper therapy usually results in little or no scarring.
Once the frequency of topical corticosteroid drops is tapered to 2 or 3 instillations per day. usually 4 to 7 days.General Observations • • • • • • About 50.000 new cases each year in the U. and can be concurrent. When treating herpes simplex disease. Leading cause of corneal opacification Common cause of unilateral red eye with tearing. then systemic antiviral therapy with acyclovir (or Famvir or Valtrex) at ½ the mg. acyclovir is dosed at 800 mg 5xD for 7 days when treating herpes zoster ophthalmicus. then 4 to 5 times daily for 4 to 7 more days. dosage used in zoster therapy can be successfully used. Preservative-Free artificial tears can be added every hour or two between the trifluridine drops. but is usually delayed weeks or months after an episode of epithelial disease Focal stromal opacification is a critical slit-lamp finding. For example. Always cycloplege (usually with 5% homatropine) if there is any significant corneal involvement or anterior chamber reaction Clinical Observations of Stromal Disease • • • • • Stromal involvement. Adding artificial tears to any medical treatment is helpful in re-establishing corneal tissue integrity If patient is-or becomes-allergic to tripluridine. when it does occur. both of which are generally responsive to steroids Medical Management of Stromal Disease • It is the judicious use of topical corticosteroids initially along with topical antiviral coverage that is critical in the management of stromal disease. it is usual to stop or taper the antiviral coverage . irritation. and sometimes decreased vision Fellow eye is not at risk to develop infection History of cold sores or fever blisters is occasionally helpful in diagnosis Fluorescein tends to stain the central ulcer bed. whereas rose bengal or lissamine green tends to stain the leading edges of viral proliferation Medical Management of Epithelial Disease • • • Trifluridine solution is administered one drop every two hours until the epithelial lesion is mostly healed. 400 mg 5xD for 7 days would be used. cell-mediated (lymphocyte-plasma cell) hypersensitivity in nature.S. photophobia. can significantly complicate the management of herpetic keratitis Even minor stromal involvement can retard the rate and quality of reepithelialization Seen in about one-fifth of cases. This usually occurs beneath the epithelial lesion (or where the epithelial lesion was located) Stromal inflammatory disease can be antigen-antibody-complement mediated and/or delayed.
For patients having 2 or more recurrent herpetic episodes within a relatively short time frame (for example. a mild secondary iridocyclitis is a common accompaniment and the iridocyclitis is managed largely via cycloplegia Tapering the topical corticosteroid eye drops usually is a long. tedious process often taking many months. Most patients have to maintain daily or every other day administration indefinitely Once the active stromal inflammation is under control. This knowledge was originally published in the July 30. prophylax against recurrence with an oral antiviral. it has become standard-of-care to "treat" these patients with 400 mg of acyclovir (ACV) b.d. . 1998 New England Journal of Medicine and established this new standard of patient management.• • • Once the stroma becomes involved.i. for a year or two. Such prophylactic intervention has been shown to decrease the rate of herptic reoccurrence be 40 to 50%. less than 3 To 4 months apart).