1. Viral Keratitis

2. CORNEAL DENDRITE What else do you want to know about this patient? What would be your initial treatment? Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database Syst Rev. 2010 Dec8;(12) 2

3. RISK FACTORS: REFRACTORY AND RECURRENT 3 Mucci JJ, Utz VM, Galor A, Feuer W, Jeng BH. Recurrence rates of herpes simplex virus keratitis in contact lens and non-contact lens wearers. Eye Contact Lens. 2009 Jul;35(4):185-7.

4. Why use others? –valacyclovir (Valtrex) –famciclovir (Famvir) Why not topicial trifluridine? ORAL ANTIVIRALS 4 Nguyen DQ, Srinivasan S, Hiscott P, Kaye SB. Thimerosal-induced limbal stem cell failure: report of a case and review of the literature. Eye Contact Lens. 2007 Jul;33(4):196-8. Loutsch JM, Sainz B Jr, Marquart ME, Zheng X, Kesavan P, Higaki S, Hill JM, Tal-Singer R. Effect of famciclovir on herpes simplex virus type 1 corneal disease and establishment of latency in rabbits. Antimicrob Agents Chemother. 2001 Jul;45(7):2044-53. Why do most ophthalmologists still use acyclovir as their oral agent of choice?

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6. Cost of Oral Antivirals 6 WHOLESALE COSTPer Pill1 month Generic valacyclovir 500 mg tab $0.8475$25.43 (500mg) Generic famciclovir 500 mg tab $1.6906$50.72 Generic acyclovir 400 mg tab$1.2700$76.20 (800mg)

7. MARGINAL KERATITIS? 7

8. IV or oral suspension Long term prophylaxis: dose reviewed at least every 6 months (weight based!) Dose: –Over 40kg – 400mg bid –30mg/kg/day divided q8h CHILDREN 8

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10. HZV – HSV FACE OFF 10

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12. STROMAL KERATITIS? 12

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14. HOW DID WE GET HERE? 14

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16. NEUROTROPHIC ULCER V. PERSISTENT EPITHELIAL DEFECT 16

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19. AAO guidelines: –5 minute soak: 70% ehtyl ethanol 1:10 sodium hypochlorite (bleach) Gloves / Isolation room / Avoid waiting room Avoid contact with surfaces / instruments / drops DISINFECTION AND HYGIENE 19

20. Povidone-Iodine 0.5% QID + Dexamethasone 0.1% QID x 10 days Povidone-Iodine 5% wash? Gancilovir gel (special access)? The RPS Adeno Detector (Rapid Pathogen Screening) Mixed results in studies ACUTE TREATMENT 20

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22. WHEN TO TREAT 22 VISION PAIN SEVERE

23. 9 patients (12 eyes) with 13month follow-up Steroid failures or “responders” Cyclosporine 1% BID Conclusion: –IOP normalized and reduced medications –All patients stable (1/3) or improved (2/3) –Severity of symptoms improved –Trend of improved vision (2 lines) TORONTO WESTERN HOSPITAL 23

24. TAKE HOME POINTS 24 Be aggressive with epithelial defects in neurotrophic corneas: punctal cautery, tarsorraphy, serum tears Don’t debride routine or high risk HSV dendrites Have your hospital stock viral cultures Oral and topical antiviral for HZV pseudo-dendrites Prevent and perhaps treat adenoviral conjunctivitis Zostavax: the vaccine for your cataract patients!

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26. One million new episodes world-wide per year (epithelial keratitis), 5000 per year in Canada 0.014% Besides HSV-1, much less common causes of dendritic epithelial keratitis: –HSV-2 –Varicella-zoster virus –Co-infection with HSV-1 and human herpes virus 6 –Very rarely, cytomegalovirus, epstein-barr virus, or adenovirus Pseudodendrite: esp day 1 abrasion, exposure keratopathy, neurotrophic cornea (esp diabetic) QUICK FACTS 26