What is included in the treatment of stromal keratitis?

Updated: Jan 18, 2019
  • Author: Jim C Wang (王崇安), MD; Chief Editor: Andrew A Dahl, MD, FACS  more...
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Prior to the treatment of stromal disease, the status of the epithelium needs to be evaluated. If stromal disease is accompanied with a concomitant epithelial defect, it is treated similarly to epithelial keratitis, with a topical antiviral agent and a cycloplegic agent administered until the epithelium has healed. [23] Immune stromal keratitis without associated epithelial disease or necrotizing stromal keratitis after resolution of the epithelial defect are treated with the following:

  • Topical corticosteroids

  • Topical or oral antivirals

The strategy for topical corticosteroid therapy is frequent initial administration (q1-4h) followed by slow tapering of the dose to the lowest effective amount. [24]

Topical or oral antivirals are recommended to prevent or limit epithelial disease during treatment with corticosteroids. [25] Many recommendations are available on the frequency of administration of antivirals for prophylaxis. A most commonly used regimen includes administering the drops as often as the recommended therapeutic dose needed to treat epithelial disease.

Another regimen includes initiating and tapering the antiviral in the same dosage as the corticosteroid until corticosteroid therapy tapers down to once a day, at which time the topical antiviral is discontinued. The Herpetic Eye Disease Study Group recommended using trifluridine, 4 times daily for 3 weeks and 2 times daily thereafter.

Associated elevated intraocular pressure can be treated with timolol and systemic acetazolamide, as necessary.

Topical cyclosporin A 2% drops in an uncontrolled study showed efficacy in the treatment of stromal disease without the use of corticosteroids. A role may exist for this medication in those patients unable to use corticosteroids. [26]

Indolent stromal ulceration is managed with antiviral and corticosteroid therapy along with a soft contact lens to prevent corneal drying. When melting of the cornea occurs, care must be taken not to stop corticosteroid therapy abruptly, as doing so may lead to rebound inflammation and increase the melting process, thereby resulting in perforation. The anticollagenolytic activity of tetracycline may help retard corneal melting.

Consider the possibility of medication-induced toxicity or an anesthetic cornea when faced with chronic, nonhealing epithelial defects associated with stromal inflammation. Occasionally, a lateral tarsorrhaphy may be required to treat a nonhealing epithelial defect.

Anti-VEGF agents (bevacizumab, ranibizumab), fine-needle diathermy, and photodynamic therapy have all been reported as successful in treating stable persistent corneal neovascularization due to HSV keratitis.

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