Management of Herpes Simplex Virus Stromal Keratitis: An Evidence-based Review

Herpes simplex virus (HSV) stromal keratitis is a leading cause of corneal opacification and an important indication for penetrating keratoplasty. Based on several observational studies and clinical trials, the current standard of care includes topical corticosteroids and antivirals. However, corticosteroids have significant side effects, and antivirals are only beneficial if replicating virus is present. High-quality clinical trials investigating therapies for HSV stromal keratitis beyond corticosteroids and antivirals are lacking. Immune regulatory drugs, such as cyclosporine A, present attractive alternatives to managing HSV stromal keratitis, given the immune-mediated pathogenesis of stromal disease. Also, inhibiting viral reactivation in the latently infected ganglia through therapeutic vaccination will likely be the most efficient avenue to reduce recurrent HSV ocular disease. Our present aim is to review the current evidence-based treatment options for HSV stromal keratitis including and beyond the use of corticosteroids and antivirals and to cultivate insights into developing therapeutic vaccination strategies to inhibit HSV stromal keratitis recurrences.