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Managing Herpes Simplex Keratitis from Wider Public Health Contexts to Individual Patient Perspectives

Ultimately, there are many ways to help patients feel at ease, alleviate concerns from prior episodes, and stress the importance of early treatment

By: Bela Parekh, MD, JAI G. PAREKH, MD, MBA, FAAO
Ophthalmology Management October 1, 2024

This article was originally published in a sponsored newsletter.

Herpes simplex keratitis (HSV keratitis) is a significant ocular condition with potentially serious long-term consequences. It is the leading cause of infectious corneal blindness worldwide, with an estimated 40,000 new cases of severe monocular visual impairment or blindness occurring annually.1,2 The course of HSV keratitis differs markedly between treated and untreated cases. With proper treatment, most epithelial infections resolve within two weeks, and even more complex stromal involvements can be managed effectively with a combination of antivirals and carefully administered steroids.3 Long-term prophylaxis with oral antivirals has been shown to reduce recurrence rates by approximately 45%.3

Outcomes for patients with recurrent HSV keratitis have improved dramatically in recent years, thanks to advancements in treatment options and management strategies. Historically, recurrent HSV keratitis often led to severe corneal scarring and even blindness, necessitating corneal transplantation.4 However, with the advent of effective oral antivirals and prompt treatment of recurrences, patient prognoses have significantly improved. Older topicals sometimes contributed to ocular surface toxicity, especially with frequent dosing 7 to 9 times per day, but newer medications such as ganciclovir gel (Zirgan, Bausch + Lomb), which has a more comfortable formulation, can be used much less frequently and present less risk of medication toxicity.5

Still, methods to combat infections should be undertaken both systemically and on the individual patient level.

Public Health Approaches

On a public health level, steps such as improving access to antiviral medications; increasing public awareness and supporting research; and implementing standardized treatment protocols globally are necessary.

  • Improved Access to Antiviral Therapies: We must ensure the availability and affordability of effective antiviral treatments, such as acyclovir and newer agents, in resource-limited settings.5

  • Vaccination and Other Research: Development and deployment of vaccines is underway to prevent primary HSV infections and reduce recurrence rates.5  Research in corneal nerve regeneration, novel antivirals and new drug delivery methods also shows promise for improving future HSV keratitis treatment.6

    CRISPR-Cas9 technology is another innovation in development. It has demonstrated efficacy in eradicating HSV-1 in mouse models, potentially preventing recurrence and reducing the viral reservoir in the trigeminal ganglia.7

    Novel drug delivery systems, such as nanocarriers and in situ gelling systems, are also being explored as methods of enhancing the bioavailability and efficacy of antiviral agents while minimizing systemic toxicity.8

  • Public Health Education: The general public would benefit from increased awareness about HSV transmission and the importance of early treatment to prevent complications.

By addressing these aspects comprehensively, the global impact of HSV keratitis could be significantly reduced, preserving vision and improving quality of life for millions of people worldwide.2

Focuses for Individual Patient Care

Patient Education: Counseling patients on preventing recurrences is a crucial aspect of managing HSV keratitis.

  • Health-care providers should educate patients about potential lifestyle triggers, including stress, fever, ocular trauma, UV exposure and compromised immune health.
  • Recommending long-term oral antiviral prophylaxis for high-risk patients, emphasizing the importance of prompt treatment at the first sign of recurrence, and stressing the need for regular follow-ups are all key components of patient education.

Compliance Management: Compliance issues are common in the treatment of HSV keratitis, but several strategies can help:

  • Frequent follow-up visits allow for close monitoring and reinforcement of treatment importance.
  • Newer medications with simplified dosing regimens can improve compliance.
  • Clear explanations of the treatment rationale, potential complications of non-compliance, and the importance of completing full treatment courses are crucial.
  • Promptly addressing side effects and suggesting the use of reminders can also enhance adherence.

Patient Concerns and Compliance: Managing patient hesitancy due to previous negative experiences, cost concerns, or worries about continued treatment requires a thoughtful approach. Ultimately, there are many ways to help patients feel at ease, alleviate concerns from prior episodes, and stress the importance of early treatment:

  • Provide education about the disease process and potential complications.
  • Address previous negative experiences by explaining improvements in current treatments.
  • Emphasize the risks of untreated disease, such as vision loss and the need for corneal transplantation, or the development of uveitis secondary to herpes simplex, as well as the risks of possible treatment with corneal transplantation, including rejection or graft vs. host disease.
  • Explore patient assistance programs or generic options if there are concerns regarding costs.

References:

  1. Chodosh J, Ung L. Adoption of innovation in herpes simplex virus keratitis. Cornea. 2020 Nov;39(1):S7-S18. doi:10.1097/ICO.0000000000002425
  2. McCormick I, James C, Welton N, et al. Incidence of herpes simplex virus keratitis and other ocular disease: global review and estimates. Ophthalmic Epidemiol. 2022 Aug;29(4):353-362. doi:10.1080/09286586.2021.1962919
  3. Burling L, Asbell PA, Cohen EJ, Tuli SS. Key cornea trials: the legacy of HEDS, the promise of ZEDS. July 1, 2021. Accessed September 26, 2024. https://www.aao.org/eyenet/article/key-cornea-trials-legacy-of-heds-promise-of-zeds
  4. Austin A, Lietman T, Rose-Nussbaumer J. Update on the management of infectious keratitis. Ophthalmology. 2017 Nov;124(11):1678-1689. doi:10.1016/j.ophtha.2017.05.012
  5. Roozbahani M, Hammersmith KM. Management of herpes simplex virus epithelial keratitis. Curr Opin Ophthalmol. 2018 Jul;29(4):360-364. doi:10.1097/ICU.0000000000000483.
  6. Moein H-R, Kheirkhah A, Muller RT, Cruzat AC, Pavan-Langston D, Hamrah P. Corneal nerve regeneration after herpes simplex keratitis: a longitudinal in vivo confocal microscopy study. Ocul Surf. 2018 Apr;16(2):218-225. doi:10.1016/j.jtos.2017.12.001
  7. Yin D, Ling S, Wang D, et al. Targeting herpes simplex virus with CRISPR-Cas9 cures herpetic stromal keratitis in mice. Nat Biotechnol. 2021 May;39(5):567-577. doi: 10.1038/s41587-020-00781-8
  8. Pandey M, Choudhury H, Abdul-Aziz A, et al. Advancement on sustained antiviral ocular drug delivery for herpes simplex virus keratitis: recent update on potential investigation. Pharmaceutics. 2020 Dec;13(1):1. doi: 10.3390/pharmaceutics13010001

 

Bela Parekh, MD is a first year ophthalmology resident (PGY-1) at Wills Eye Hospital / Thomas Jefferson University in Philadelphia, PA. Before medical school, she spent time in management consulting, where she helped develop R&D strategies for pharmaceutical companies.

JAI G. PAREKH, MD, MBA, FAAO is the co-founder of EyeCare Consultants of NJ. He is also Chief of Anterior Segment Ocular Surgery and the Medical Director of the Research Institute at St. Joseph's Health System, NJ. Dr. Parekh also serves on the Cornea Service at the New York Eye & Ear Infirmary of the Icahn School of Medicine at Mt. Sinai (NY) where he is also Clinical Associate Professor.

 

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