Subconjunctival triamcinolone for the treatment of chronic stromal herpes simplex keratitis

1. Subconjunctivaltriamcinolone for the treatment of chronic stromal herpes simplex keratitis Y.Athanasiadis, G.Nithyanandrajah, D.Bishop, P. Scollo, A.Sharma Moorfields Eye Hospital, UK Authors have no financial interest

2. HISTORY • A 29 year female. No atopy • Left Herpes simplex keratitis (HSK) first episode 1997. Right eye normal. • Steroid drops since then with acyclovir ointment. Initially flare up every year requiring hourly steroid drops for 1 to 2 days which reduced symptoms. • From 2003 frequency of painful episodes worsening slowly and by 2008 up to 1 attack per month. • During flare ups very painful and aversion to bright lights even with sunglasses. In between flare ups just bearable with sunglasses in bright lights , gritty watery eye, shooting pains in the eye. Cold compression often used to relieve the pain. • Referred for left corneal transplant in 2010. Visual acuities right 6/6 and left 6/36 unaided (improving to 6/24 with pin hole).

3. MANAGEMENT • Left cautery to corneal vessels and subconjunctival triamcinolone acetonide (SCTA) in 2010 in preparation for corneal transplant. • Oral Aciclovir400mg twice a day from 2010 to 2012 (stopped due to pregnancy and bowel irritation) • Next day after SCTA left eye felt ‘amazingly comfortable’ and did not want a corneal transplant if eye remained so. Since then white corneal scar and vision slowly improved, Visual acuities at the time, right 6/6 and left 6/36 unaided improving to 6/18 with pinhole. • Repeat SCTA on average every 12 months as symptoms and signs recurring. • One day post SCTA • 18 week post SCTA

4. Herpetic Eye Disease Study (HEDS) • Steroid drops speed up resolution of stromal keratitis and fewer treatment failures. • Oral acyclovir 400mg bd over a year, reduced the recurrence of stromal keratitis by almost 50%.

5. Subconjunctivaltriamcinolone for Herpes simplex stromalkeratitis • The role of HSK in stromal keratitis has not been clearly understood. • In stromal disciform keratitis the main cause of inflammation is considered to be Antigen-Antibody complement mediated immune reaction and not active viral infection of stromal keratocytes. Whereas live HSV infection and the accompanying reaction as the main cause of necrotizing stromal keratitis. • However HSV DNA has been detected in 8 out of 14 active disciform keratitis cases ( Fukuda et al 2003) suggesting active viral replication occurs in some cases of disciform keratitis. Intracellular virions have also been seen in clinically ‘inactive’ disease (Awan et al 2010) • Patients undergoing corneal graft for herpes simplex virus (HSV) keratitis are at higher risk for adverse corneal allograft outcomes when compared with individuals undergoing grafting for conditions such as keratoconus and Fuchs’ corneal dystrophy particularly when transplant surgery is carried out on active disease.

6. Subconjunctivaltriamcinolone for Herpes simplex stromalkeratitis • Some stromal keratitis patients are steroid dependent and require a regular amount of topical steroids to prevent recurrence. The reason for long term steroid dependency is unclear. • Our case is a severe example of steroid dependent stromalkeratitis. • SCTA provided a much more comfortable eye than hourly steroids for this patient and this may be because of the constant steroid presence. This has been shown to be helpful in corneal transplant rejection and treatment of new corneal vessels. • SCTA has been used before in HSK prior to acyclovir. In the authors view SCTA for HSK is safer with the use of oral acyclovir. However, side effects include raised IOP, which can be reversed by surgical removal of the SCTA , did not occur in the our case. • Inferior white deposit of subconjunctival triamcinolone (SCTA) • 4 days post SCTA • 18 weeks post SCTA