There is indeed an excellent, highly effective, easily applied and very cost-effective
treatment for acute EKC. To maximize therapeutic response in viral infections,
initiate therapy early in the disease process.
Dear Drs. Melton and Thomas,
I am an O.D. in a seven-doctor
The majority of my patients are
within the realm of corneal disease,
as I work closely with our corneal
I was intrigued when I read your
recent article in the November
2008 issue of Review of Optometry,
regarding the use of 5%
Betadine to treat acute EKC. From
December 2006 through March
2007, we had an outbreak of a very
aggressive strain of EKC among
our three offices. While we did see
patients who were obviously
through our office (we seriously
amended our cleaning and disinfecting
protocols), we also saw
patients new to our office with
EKC. All in all, we saw close to
275 patients during that time with
EKC. Yet, in my research, I never
found anything like your protocol.
Upon reading the recent article, I
decided I would implement treatment
on the next acute EKC
patients that I saw in the office. I
treated four patients the month of
January, one of whom was a technician,
two confirmed with the RPS
test. All had improvement of their
symptoms within two days, and
resolution within four to five days.
None developed infiltrates or membranes.
I find it curious that most of
optometry and ophthalmology have
not embraced this treatment. I
spoke with a colleague regarding
the treatment and he was not
impressed. His response was that
they will get better in a week anyway. Most of the doctors (M.D.s)
within my practice had never heard
of this treatment, including one
who recently completed his fellowship
in anterior segment. I can tell
you in 12 years of practicing, I have
never seen true EKC clear up in a
week. These patients are miserable,
uncomfortable, and unable to
work. Perhaps after seeing nearly
200 patients during that outbreak
has hyper-sensitized me.
I work closely with a corneal specialist.
He shares my opinion that
this is not well embraced and that
extensive research into some
obscure ophthalmology journals is
required to even find mention of
off-label 5% Betadine use to treat
As primary care providers,
optometry needs to embrace this
treatment and put it into practice.
All that is required is a careful history
and slit lamp biomicroscope,
as well as some 5% Betadine.
Again, thank you for your time
and for the fascinating article.
To further illuminate the dismal
awareness of this excellent, offlabel,
medical treatment, let’s look
at the following two quotes from
the contemporary medical literature:
“Unfortunately, no effective
treatment has been found for viral
— Ohnsman CM. Study looks at
exclusion of students with conjunctivitis
from school. Ocular Surgery
News. 2007 April 15;25(8):160-3.
“Since the initial description of
epidemic adenoviral ocular infections
in Austria in 1889 until the
present day, no effective drug to
treat such patients has been found.
Today, acute adenoviral ocular
infections (epidemic keratoconjunctivitis,
follicular conjunctivitis, and
pharyngeal conjunctival fever)
remain among the most common
external ocular viral infections seen
clinically worldwide … There are
51 serotypes of adenovirus, of
which approximately one-half have
been shown to cause ocular disease.
The American Academy of
Ophthalmology Preferred Practice
Pattern proposes symptomatic
treatment for these infections and
the use of topical steroids to reduce
scarring in severe cases of adenoviral
marked chemosis or lid swelling,
epithelial sloughing, or membranous
conjunctivitis. Lacking an
effective Food and Drug Administration-
approved antiviral, clinicians
recognize the continuing need
to develop a drug to reduce patient
morbidity, to reduce the extent of
or entirely prevent the formation of
vision-altering subepithelial infiltrates,
to reduce lost time from school or work, and to reduce or
prevent the transmission of ocular
infections within households, communities,
and medical facilities.”
— Romanowski EG, Gordon YJ.
Update on antiviral treatment of
adenoviral ocular infections. Am J
Ophthalmol. 2008 Nov;146(5):
The good news is there is indeed
an excellent, highly effective, easily
applied and incredibly cost-effective
treatment therapy for acute EKC.
The key to a maximal therapeutic
response in viral infections is to initiate
therapy early in the course of
the disease process.
Let’s look at the clinical features
of acute EKC. Almost all of these
patients present with a history of
acute redness starting in one eye,
and spreading to the fellow eye in
two to three days. A watery discharge
is a constant feature. A
palpable preauricular node is commonly
detected (if one feels for it)
on the side of the initially infected
eye. In more advanced cases, the
bulbar conjunctiva can demonstrate
multiple petechial hemorrhages,
most commonly seen superiorly.
Bacterial conjunctivitis can have
variably expressed microvascular
injection of the conjunctiva, and
evident mucopurulent discharge.
Only in “hyperacute” bacterial conjunctivitis
is there evident preauricular
lymph adenopathy. If
diagnostic certainly is elusive, the
RPS Adeno Detector (www.rpstests.
com) may be helpful.
When we encounter a patient
with moderate to advanced EKC,
we generally treat them via the following
- By history, rule out any allergy
or sensitivity to iodine, the molecular
backbone of Betadine.
- Instill a drop of 0.5% proparacaine,
as Betadine (like tropicamide)
stings upon instillation.
- Betadine can cause mild stippling
to the corneal epithelium
resulting in marked stinging. So
instill a drop or two of a topical
- Instill four to five drops of
Betadine onto the eye.
- Ask the patient to gently close the eyes and roll them around to
ensure thorough distribution of the
Betadine across the ocular surfaces.
- After one minute, lavage out
the Betadine (to avoid any unnecessary
toxicity and discoloration of
the tissues) with any sterile ophthalmic
- Just for good measure, instill
another drop or two of the
NSAID (or even proparacaine if
the patient has any discomfort).
We have now essentially eliminated
the adenoviral load; but
of course, we’ve done nothing
for the secondarily inflamed
conjunctival tissues. To address
the inflammatory component,
prescribe Lotemax q.i.d. for
Between the two of us, we have
used this procedure more than 200
times now and find it enormously
helpful for our patients with acute
EKC. More importantly, we have
queried audiences all across the
country, and have yet to find any
optometrist who reports anything
other than success with use of this
In addition to EKC adenoviral
infection, there are two additional
viral infections that are clinically
important: herpes simplex and varicella
We should be well prepared to
diagnose and competently intervene
therapeutically on behalf of patients
with diseases caused by these
Herpes Simplex Virus
Herpes simplex viruses (HSV) are
responsible for nearly 50,000 new
and recurring cases of HSV keratitis
each year in the United States.1 HSV
almost exclusively manifests as dendritiform
or geographic epithelial
Fortunately, we have
a tried-and-true, FDAapproved
kill the herpes simplex
virus, available both
generically as trifluridine
solution and by its
original brand name of
drop to the
every two hours
(while awake) for four to
five days, then q.i.d. for
four or five more days,
depending upon the individual
response. Preservative-free artificial
tears are the only other eye drops that might be helpful in conjunction
with this topical approach.
Then again, many doctors now
bypass topical therapy and simply
initiate therapy with an oral antiviral,
such as 400mg of oral acyclovir
five times a day for one week or
Valtrex (valacyclovir, GlaxoSmith-
Kline) 500mg t.i.d. for one week.
Herpes Zoster (Varicella
The head and/or face is the second
most common site (after the
trunk) for the expression of shingles.
More specifically, the ophthalmic
(or first) division of the
trigeminal nerve is the most common
head/face site of expression.
Regardless of site, the treatment is
uniform: 800mg of acyclovir (ACV)
p.o. five times a day for one week.
Patients are commonly sent to
eye doctors by internists, dermatologists
and family physicians to rule
out eye involvement. Sometimes
patients with head/face shingles
simply present first to an eye doctor
for care. In either case, it is essential
to assess the global tissues, looking
specifically for anterior uveitis
and/or an inflammatory keratitis, as
these are by far the most common
eye manifestations of the VZ virus.
The eye itself is involved in approximately
half of all ophthalmic division
cases.2 The rest are simply
dermatologic cases. If the eye is
involved, it is always an expression
of inflammation, and is usually
quickly controlled with the aggressive
use of a potent corticosteroid
such as Lotemax or Pred Forte.
Since the herpes viruses are neurotrophic,
afferent sensation can be
perturbed for many months after
successfully treating the initial
zoster disease. Such post-herpetic
neuralgia is probably best treated
by a primary-care physician or dermatologist.
Treatment is generally
accomplished with a tricyclic antidepressant,
such as amitriptyline,
For cases of chicken pox occurring
in children over the age of two
and generally weighing over 40lbs.,
the FDA’s and CDC’s recommended
dosage of ACV is up to 800mg
q.i.d. for one week, depending upon
the weight of the patient. We think
this strongly demonstrates the
safety of these antivirals.
There are three oral antivirals
currently available. Besides acyclovir
there is valacyclovir (Valtrex,
GlaxoSmithKline) and famciclovir
(Famvir, Novartis). Valtrex’s zoster
dosage is 1,000mg t.i.d. for one
week. For herpes simplex, it is
dosed at 500mg t.i.d. for one week.
Famvir’s zoster dosage is 500mg
t.i.d. for one week; for herpes simplex,
it is dosed at 250mg t.i.d. for
one week. All three drugs are minimally
biologically active until they
are activated via viral thymidine
kinase phosphorylation. This wonderfully
unique mechanism of viral
kinase activation is the mechanism
that makes this class of oral antivirals
so safe, yet so highly effective.
These medicines are maximally
effective when instituted within the
first three days of disease manifestation;
however, they still render a
positive therapeutic effect when
used even five, six or seven days
into the disease event. Keep this in
mind so that patients will not be
denied proper medical care.
One area of caution with regard
to these oral antivirals is renal disease.
Since these drugs are excreted
via the kidneys, make sure there is
no known kidney disease. If there is
kidney function impairment, then
call the patient’s nephrologist or
primary care physician to learn the
patient’s creatinine clearance value.
You should then have a telephone
visit with a pharmacist or the
patient’s physician who, via a quick
and simple computer program, will
be able to calculate the appropriate
antiviral dosage for your patient
based upon this value. It’s very
In summary, there are excellent,
safe and highly effective drugs
available to treat viral diseases
afflicting the human eye: 5% ophthalmic
Betadine for EKC, trifluridine
(or oral antivirals) for
epithelial herpes simplex, and oral
antivirals for shingles and/or
chicken pox. When properly
applied, these drugs bring rapid
relief to nearly all patients.
- Liesegang TJ. Herpes simplex virus epidemiology and
ocular importance. Cornea 2001 Jan;20(1):1-13. Review.
- Pavan-Langston D. Herpes zoster ophthalmicus.
Neurology 1995 Dec;45(12 Suppl 8):S50-1.