Topical corticosteroids are the mainstay of treatment for HSV iritis. Cycloplegic agents may be helpful to decrease symptoms of photophobia and decrease or lyse posterior synechiae.
Topical antiviral agents may help to prevent dendritic keratitis during treatment with corticosteroids, in patients with keratouveitis. In general topical antivirals are of little use in the treatment of HSV iritis, since these agents do not penetrate well into the anterior chamber. In fact, topical antiviral agents may be detrimental due to their topical toxicity. Systemic antiviral agents, such as acyclovir, famcyclovir, or valacyclovir, attain excellent anterior chamber drug levels and may be beneficial in cases of iritis. The HEDS study’s [link to HEDS page] trial of acyclovir in the treatment of HSV iritis was stopped prior to meeting the number of subjects needed according to the sample size estimates. This was done because of problems with recruitment. In the findings that were published, there was a statistically suggestive trend for more rapid resolution of iritis with the use of systemic acyclovir, 400 mg five times per day.
Appropriate doses of systemic antiviral agents for treating active ocular disease are: acyclovir, 400 mg five times per day; valacyclovir, 1000 mg twice per day; famciclovir 250 mg three times per day.