Question

What is the protocol of managing a patient with recurrent herpetic kerato-uveitis?

Hint:

Recurrent herpetic kerato-uveitis requires a balance between antiviral and anti-inflammatory therapies. Topical steroids should only be used after viral control is achieved to prevent exacerbating the infection.

Answer 1

Step 1: Management of Recurrent Herpetic Kerato-Uveitis.
Recurrent herpetic kerato-uveitis (HKU) is a complex condition that involves both the cornea and the uveal tract (the iris, ciliary body, and choroi. Management typically requires a multi-disciplinary approach, combining antiviral therapy and anti-inflammatory treatment. The protocol includes:
(1) Antiviral Therapy:
- Oral Antivirals: Acyclovir (400 mg 5 times a day), valacyclovir, or famciclovir are commonly used oral antivirals to suppress the viral replication.
- Topical Antivirals: Trifluorothymidine (TFT) or ganciclovir gel may be prescribed to control corneal involvement. Topical antivirals are typically used in active epithelial keratitis, though they should be avoided in the presence of uveitis.
- The goal is to decrease viral replication, which can trigger recurrent episodes of inflammation.
(2) Anti-inflammatory Therapy:
- Topical Steroids: After viral suppression, topical corticosteroids (e.g., prednisolone acetate) may be used to manage inflammation in the uveal tract (iritis or anterior uveitis). However, these should only be used under careful supervision because steroids can worsen viral replication in the cornea.
- Cycloplegics (Atropine, Homatropine): These are used to control pain and prevent synechiae formation by relaxing the ciliary muscle and dilating the pupil.
(3) Systemic Steroids (in severe cases):
- For severe or recalcitrant cases of herpetic uveitis, systemic steroids may be required, though these should be used with caution due to the potential for reactivation of HSV.
(4) Monitoring and Follow-up:
- Patients should be monitored closely to ensure that inflammation is controlled and that no complications (e.g., glaucoma, cataract formation, retinal complications) arise.
- Regular slit-lamp examinations and fundus evaluations are necessary to monitor for any posterior segment involvement.