|When used together with an antiviral such as acyclovir, corticosteroid treatments could be more effective for herpes stromal keratitis compared with monotherapy of an antiviral or corticosteroid. Photo: Christine Sindt, OD. Click image to enlarge.|
Among classifications of herpes simplex keratitis, herpes stromal keratitis is a leading cause of irreversible corneal scarring, thinning, neovascularization and infectious blindness worldwide. Disease outcomes including vision loss, neovascularization and angiogenesis may progressively worsen after each recurrence. The standard treatment for herpes stromal keratitis includes antiviral medications in combination with corticosteroids, which addresses both the viral and immunomodulatory pathogenicity of the condition by reducing inflammation and inhibiting herpes simplex virus replication in the corneal stroma. Researchers recently conducted a systematic review to identify and compare interventions for treating herpes stromal keratitis and patient outcomes. They found that corticosteroids and antivirals managed the condition most effectively only when used concurrently. Results fared better than using either as monotherapy.
Two independent reviewers screened 168 records and used seven papers for data extraction. The research team examined both the conventional treatment with corticosteroids and antivirals and potential alternatives such as flurbiprofen, cyclosporine A and tacrolimus by their treatment success rate, best-corrected visual acuity (BCVA), resolution time of successful treatment, time to failure, IOP and adverse events.
Patients with herpes stromal keratitis who received prednisolone phosphate and acyclovir showed a higher treatment success rate and significantly longer time to failure compared with patients receiving only acyclovir. No difference in resolution time was found between oral and topical acyclovir. Between groups receiving dexamethasone and flurbiprofen, resolution occurred in 93% and 67% of patients and BCVA (logMAR) improved from 1.0 to 0.30 and 0.48, respectively. BCVA improved in both cyclosporine A and its control (prednisolone) groups. A tacrolimus treatment group showed greater improvement in BCVA compared with its control (prednisolone) group.
“These interventions could be potential novel approaches to the management of herpes stromal keratitis and allow health practitioners and patients—especially those who are unsuccessful with the standard treatment—to have access to alternative treatment plans that could be equally effective and potentially safer with fewer side effects,” the authors wrote in their paper in Ophthalmic Epidemiology.
Li X, Nayeni M, Malvankar-Mehta MS. Antiviral and anti-inflammatory therapeutic interventions for treating herpes stromal keratitis: a systematic review. Ophthalmic Epidemiol. May 15, 2023. [Epub ahead of print].