Dry eye therapies improve stromal HSK frequency, severity

Norfolk, VA-Topical cyclosporine emulsion 0.05% (Restasis, Allergan) and/or punctal occlusion may be considered for the management of stromal herpes simplex keratitis (HSK) and concomitant dry eye, said John D. Sheppard, MD.

Importantly, the review also showed a trend for treatment with punctal occlusion and/or topical cyclosporine to reduce the need for topical steroid therapy, reported Dr. Sheppard, professor of ophthalmology, microbiology, and molecular cell biology, Eastern Virginia Medical School, Norfolk.

"Patients with herpetic stromal disease are the regulars in a corneal and external disease practice," Dr. Sheppard said. "The prophylactic efficacy of oral antiviral agents is still somewhat controversial, and while topical steroids have clear benefit, there are well-known risks associated with long-term use.

"Clearly, there is a need for safe and effective alternatives to prevent recurrences and minimize morbidity in these challenging conditions. The results of this study strongly suggest efficacy of topical cyclosporine with or without punctal occlusion in that regard and also as a possible steroid-sparing strategy," Dr. Sheppard said.

He noted either punctal occlusion or treatment with topical cyclosporine might be considered for patients with stromal HSK because that disease is associated with decreased corneal sensation and a propensity to develop dry eye. Further rationale for using cyclosporine derives from the fact that corneal scarring and neovascularization in HSK are T-cell mediated, as is dry eye itself.

"Studies with topical cyclosporine 2% performed before the 0.05% emulsion preparation became commercially available demonstrated its efficacy for reducing inflammation, promoting corneal healing, and improving neovascularization," Dr. Sheppard observed.

The study Dr. Sheppard reported included 42 patients with unilateral stromal HSK and concomitant dry eye, of whom 22 had undergone ipsilateral punctal occlusion by thermal cautery, 10 were treated with cyclosporine 0.05% twice daily, and 10 started topical cyclosporine after previous punctal occlusion. All of the patients presented with disciform keratitis with central opacification, reduced corneal sensation, and other manifestations of herpetic stromal disease and were followed for at least 1 year after punctal occlusion or starting cyclosporine.

The 22 patients who underwent only ipsilateral punctal occlusion by thermal cautery were treated prior to the market introduction of topical cyclosporine emulsion. All patients continued on maintenance treatment with an oral antiviral agent (either acyclovir or valacyclovir) and were being treated with a topical corticosteroid (either prednisolone acetate 1% or loteprednol 0.5%). Attempts were always made to reduce the steroid.

HSK recurrences

In the year prior to treatment with either occlusion or cyclosporine, the mean annual HSK recurrence rates in the punctal cautery, cyclosporine, and punctal cautery + cyclosporine groups were 2.1, 1.8, and 0.58 episodes/year, respectively. During follow-up, the mean annual HSK recurrence rate was reduced significantly to ≤0.45 episodes/year in both the punctal cautery and cyclosporine groups. Among patients who began cyclosporine treatment after punctal cautery, there was also a minimally significant reduction in the mean recurrence rate to 0.40 episodes/year.

The mean duration of HSK recurrences in the punctal cautery, cyclosporine, and punctal cautery + cyclosporine groups were 3.4, 3.2, and 2.2 months, respectively. A reduction in recurrence duration was also observed in all three groups, although only the changes in the punctal cautery and cyclosporine groups were statistically significant. During follow-up, mean recurrence durations in the three treatment groups were 2.4, 2.5, and 2.0 months, respectively.