If an HSV ulcer persists for more than 2 weeks, Dr. Yeu recommends stopping topical anti-viral treatment and changing to an oral anti-viral prophylaxis, aggressive preservative-free lubrication, a therapeutic bandage over the lens (with particular caution on a neurotrophic ulcer), topical anti-bacterial coverage, self-retaining amniotic membrane, and vitamin C, omega-3 fatty acids, and doxycycline.
Treatments for keratitis caused by the live virus include valcyclovir 500 to 1,000 mg po TID, acyclovir 400 mg po 5× daily, acyclovir 0.3% ointment 5× daily (not available in the United States), ganciclovir 0.15% gel 5× daily, and trifuridine 1% every 2 hours (with caution because of toxicity), with a potential concomitant epithelial debridement to debulk the viral load.
HSV epithelial keratitis is a self-limited disease, but treating it as a live viral infection for 21 days can help expedite recovery and limit nerve damage or future immunological disease, Dr. Yeu said.
For keratitis caused by an immune-mediated reaction, antiviral prophylaxis should be instituted at the lower prophylaxis protocol as aforementioned to prevent re-activation of the active virus from the topical steroid use, according to Dr. Yeu.
Topical steroids with a very slow taper over months should be used to treat the inflammation, and may be needed once or twice a week indefinitely to maintain remission. Common high-dose topical steroids are needed, such as topical difluprednate 0.05% or prednisolone 1%, every 2 to 3 hours with a very slow taper down to weaker steroids and less frequency.