I Have a Patient With Herpes Simplex Dendrites. What Is the Best Plan to Minimize Both the Recurrences and Possible Scarring?

The large, well-organized Herpetic Eye Disease Study (HEDS) continues to guide our treatment of herpes simplex virus (HSV) keratitis (Figure 33-1). It is clear from these investigations that the initial treatment of HSV epithelial keratitis with a topical antiviral agent hastens the healing process.^1,2 Since HEDS was published, several new topical antivirals have been introduced to the market, including ganciclovir ophthalmic gel 0.15% and acyclovir ointment. Ganciclovir gel has been approved by the US Food and Drug Administration (FDA) since 2009, but acyclovir ointment has not been approved by the FDA for ocular use. Studies comparing the 2 have shown similar treatment efficacy, but ganciclovir gel was better tolerated by patients. At the time of the HEDS study, trifluridine was the most commonly used topical antiviral agent for HSV keratitis, but its use has decreased since the introduction of these newer antiviral agents due to its side effects profile, notably severe ocular surface toxicity.³ HEDS also suggested that adding an oral antiviral to topical antiviral treatment did not provide any additional benefit for treating dendritic keratitis, such as improving healing time or preventing possible additional corneal or intraocular involvement, including stromal keratitis or iridocyclitis.^1,2.