Viral Infections are more commonly encountered in individual practice than what presents in tertiary or referral eye care. Its presentation is myriad & baffling often a misdiagnosis as bacterial or fungal causing more harm. Also, with more choices on the availability of antivirals, individual practice varies. Here we discuss key presenting clinical features & know from the leading cornea experts their preferred treatment practices.
Dr. Manisha Acharya is a practicing ophthalmologist hailing from Delhi. She received her MS degree (2003) from Jawaharlal Nehru Medical College, Aligarh following which she completed her fellowship at Dr. Shroff’s Charity Eye Hospital. She has also been trained at– Bascom Palmer Eye Institute, Miami, Florida, and LVPEI, Hyderabad. She is currently working as Senior Consultant, Department of Cornea and Refractive Surgery with Dr. Shroff’s Charity Eye Hospital, New Delhi. Apart from being a proficient corneal surgeon, Dr. Acharya is the Medical Director of the Eye Bank of Dr. Shroff’s Charity Eye Hospital which is one of the rapidly growing Eye Bank in North India. Her passion and contribution to Indian eye banking have brought her laurels both nationally and internationally. She is the proud recipient of the BMJ South Asia Healthcare Award 2016 as Quality team of the year for “Improvement in Eye Bank Tissue utilization through Quality Assurance Initiatives”. She is the proud author of the book titled “Eye Bank Tissue Recovery ” which was released by the Eye Bank Association of India (EBAI) in 2019. She has several publications to her credit, and her papers on quality and training in Eye Banking are well-acknowledged around the globe.
Dr. Meena Lakshmipathy MS, is a senior Cornea consultant working in Medical Research Foundation, Sankara Netralaya, Chennai. She completed MBBS from Stanley Medical College Chennai in 1997 and subsequently completed MS Ophthalmology from Govt Rajai Hospital, Madurai Medical college in 2001. She completed Cornea and Anterior segment fellowship in 2004 from LV Prasad Eye Institute. Hyderabad and worked as a cornea consultant at GMRV LV Prasad Eye Institute. Her main interests include microbial keratitis, pediatric corneal disorders, and lamellar corneal surgeries.
Dr. Bhupesh Bagga is a Cornea fellowship trained Ophthalmologist at LV Prasad eye institute, Hyderabad, India. In addition to his clinical work, he is a researcher. His current research focus is on corneal ulcer treatment. In addition, he is involved in managing pediatric corneal disorders and complex ocular surface diseases. He is the investigator of grants related to HSV keratitis and Pythium keratitis funded by ICMR and DST. He has been actively involved in teaching postgraduates and fellow.
eOphtha: In your practice, which is the most common etiology of corneal ulcer seen?
Dr. Manisha Acharya: I practice at Dr. Shroff’s Charity Eye Hospital, New Delhi which is a tertiary eye care center and patients from entire North India come to avail of our specialized services. Our team sees approximately 375 new patients of Infective keratitis yearly which comes to about 30-35 new infective keratitis patients a month. Being a referral center, we see a lot of corneal ulcers receiving cocktail therapy for all groups of microbial organisms. As viral keratitis presents with varied presentations, it accounts for 20-30% of the ulcer patients seen.
Dr. Meena Lakshmipathy: Corneal scraping is employed in all presenting ulcers which are 2mm & above. In our practice, both fungi and bacterial ulcers are equally noted. However, culture-positive rates of fungal keratitis seem to be more compared to bacterial. Viral keratitis is clinically suspected and treated. Viral PCR for HSV keratitis is not routinely done except when the presentation is atypical and in necrotizing stromal keratitis.
Dr. Bhupesh Bagga: HSV keratitis.
eOphtha: What is the most common age group involved in viral keratitis? Also, tell us about the laterality and / most common presentation
Dr. Manisha Acharya: There is a definite male predominance seen with almost 65-70% of patients being males Most patients are adults with unilateral presentation and with a history of recurrence. The most common presentation is dendritic epithelial keratitis.
Dr. Meena Lakshmipathy: All age range are capable of being affected by HSV viral keratitis. Unilateral is the most common presentation. A high index of suspicion is needed especially when a patient reports recurrent attacks. It’s important to look for ghost scarring, thinning, and lipid keratopathy.
Bilateral presentations are rare and are reported to occur in immunocompromised status and Atopy. I do see stromal immune keratitis and nummular keratitis -typical coin-shaped lesions as the most common presentation.
Dr. Bhupesh Bagga: Males more common with stromal keratitis, Unilateral most common. Age-3rd to 5th decade.
eOphtha: What antiviral drug you use mostly? acyclovir or ganciclovir? topical & oral acyclovir or valacyclovir? When do you add topical or oral steroids? How long you continue oral antiviral prophylaxis? How often would you askfor a kidney function test?
Dr. Manisha Acharya: My management protocols are specific depending on the type of presentation of viral keratitis. Dendritic and Geographic HSV ulcers are treated with topical 3% acyclovir eye ointment five times/day. Disciform keratitis / Endotheliitis is treated with topical steroids and tapered very slowly over several months. Necrotizing Stromal Keratitis is treated with topical Acyclovir along with Oral Acyclovir 400mg, five times a day for two weeks. Topical lubrication is given to all patients as the eye is dry because of poor corneal sensations, along with cycloplegia. Oral corticosteroids are reserved in conjunction with topical corticosteroids in severe cases of immune stromal keratitis, severe diffuse endotheliitis,
I prefer topical acyclovir five times a day to ganciclovir for epithelial keratitis and oral acyclovir five times a day to valacyclovir for stromal necrotizing keratitis, immunocompromised patients, infants, and patients with iridocyclitis not responsive to topical corticosteroids. For prophylaxis in recurrent keratitis and after penetrating keratoplasty I keep the patient on oral acyclovir 400mg twice a day. Lifelong prophylaxis may be required in these cases.
To monitor the renal toxicity of Oral Acyclovir, I get a baseline KFT, and repeat it every six months for the first year and then yearly if maintained at a normal value. In cases where KFT is deranged or the patient has financial constraints, I consider shifting the patient from prophylactic oral acyclovir to prophylactic topical acyclovir also.
Dr. Meena Lakshmipathy: I have long experience with topical 3% Acyclovir eye ointment which is prescribed 5 times a day for 2 weeks. Ganciclovir is available in a gel formulation. It is less epitheliotoxic, requires only three times dosing, and probably better compliance due to these reasons.
Acyclovir ointment is however less expensive
Stromal immune keratitis, disciform keratitis, necrotizing stromal keratitis, HSV keratouveitis are known indications for topical steroid application under antiviral cover. I prescribe tablet acyclovir 400 mg five times for 2 weeks and then continue oral acyclovir 400 mg twice daily for three months when I see the patient again and usually continue for the next three months again. I repeat the renal function test once in three months.
Topical acyclovir eye ointment has good penetration and can be given in case oral acyclovir is unavailable for any reason in the conditions mentioned above. All oral antiviral drugs are to be given with caution in the elderly(>65yr), expectant mothers, pregnant women, and kidney-related ailments.
I prefer oral Acyclovir 400 mg BD as prophylaxis for recurrent HSV keratitis and have the patient continue at least one year in especially post graft patients with periodic review in between.
Oral valacyclovir has a higher bioavailability and has the advantage of less frequent dosing 0.5-1gm/ 3 times a day for 10-14 days for active cases. For prophylaxis 0.5 g-1gm / day is prescribed. Known contraindications to valacyclovir include dehydration, hemolytic uremic syndrome, and thrombocytopenic purpura
Dr. Bhupesh Bagga: For Epithelial- acyclovir eye ointment 5 times/ day. For Prophylaxis-Oral acyclovir 400 mg twice a day. For Confirmed cases with recurrences -I add oral prophylaxis and continue them for years. 6 monthly test them with KFT.
eOphtha: Would you like to consider any other tests while dealing a herpes zoster keratitis in young patients?
Dr. Manisha Acharya: Herpes Zoster in young is relatively uncommon with potentially devastating sequelae. Altered cell-mediated immunity is a risk factor. It is important to rule out HIV infection and childhood malignancy in young. Serum antibody directed against VZV represents a good surrogate marker for cell-mediated immunity.
Dr. Meena Lakshmipathy: The occurrence of HIV in young patients presenting with HIV is a strong association. It is recommended to screen for HIV status and refer accordingly. In the absence of HIV status, it’s imperative to rule out diabetes and any other causes of immunosuppression.
Dr. Bhupesh Bagga: To rule out Seropositivity for HIV/ AIDS, Immunosuppression due to some other cause. On immunosuppressants.
eOphtha: How often you encounter viral keratouveitis with secondary glaucoma? How do you treat them?
Dr. Manisha Acharya: Uveitis tends to accompany most forms of keratitis but is especially prevalent and difficult to manage in herpes zoster keratouveitis, up to 40% of patients may develop anterior uveitis. A retrospective study has found the occurrence of secondary glaucoma in 56% of such patients, however, hypotony may also develop. In addition to oral acyclovir 800 mg five times a day, topical steroids may be beneficial in decreasing the inflammation. Antiglaucoma medications should also be added in severe inflammatory glaucoma caused due to trabeculitis.
Dr. Meena Lakshmipathy: HSV keratouveitis may or may not have raised IOP but could be noted in 50 % of the case and appropriate anti-glaucoma medication barring prostaglandin analogs are recommended. CMV endothelitis can also have raised IOP but it is less common than HSV keratitis in clinical presentation.
Dr. Bhupesh Bagga: Treat Clinically. HSV is more common. RT-PCR of the AC tap is done for the diagnosis.
eOphtha: How do you treat a case of Adenoviral conjunctivitis, in absence of corneal involvement.
Dr. Manisha Acharya: Adenovirus is the most common cause of viral conjunctivitis. Treatment includes preventing transmission and complications as well as providing symptomatic relief. Patients are advised to avoid personal contacts and sharing personal items.
Cold compresses provide temporary relief, and topical corticosteroids although decrease inflammation and provide symptomatic relief, should be used judiciously. They are justified in their use in membranous and pseudomembranous conjunctivitis. A prophylactic antibiotic is also not required except in associated membranous and pseudomembranous conjunctivitis.
Dr. Meena Lakshmipathy: I give broad-spectrum fluoroquinolone 4 -6 times for 1week and any lubricant 6 times a day. If the patient complains of sticking of lid margins in the morning antibiotic ointment at bedtime helps. It is recommended to prescribe topical lubricants alone in suspected adenoviral conjunctivitis
Dr. Bhupesh Bagga: Lubricants alone.