## Management of Recurrent HSV Epithelial Keratitis **Key Point:** Recurrent HSV keratitis requires both acute antiviral therapy AND long-term suppressive oral acyclovir to reduce recurrence frequency and severity. ### Clinical Context: Recurrent Disease The patient has three episodes in 18 months, indicating frequent recurrence. This is defined as **recurrent HSV keratitis** and warrants a different management strategy than first-episode disease. **High-Yield:** Recurrent HSV keratitis is triggered by: - Stress - Fever or systemic illness - Ultraviolet exposure - Immunosuppression - Reactivation of latent virus in trigeminal nerve ### Two-Pronged Treatment Approach | Component | Dosing | Duration | Rationale | |-----------|--------|----------|----------| | **Acute therapy** | Topical acyclovir 5×/day | 7–10 days (until epithelial healing) | Treat active epithelial keratitis | | **Suppressive therapy** | Oral acyclovir 400 mg BD | 6–12 months (or longer) | Reduce recurrence by 50% | **Clinical Pearl:** Suppressive oral acyclovir significantly reduces the frequency and severity of recurrent episodes. It works by maintaining antiviral levels in the trigeminal nerve, reducing viral shedding and reactivation. ### Why Suppression is Essential Here 1. Three recurrences in 18 months = high recurrence risk 2. Suppressive therapy reduces recurrence rate from ~40–50% annually to ~20–30% 3. Prevents progression to stromal disease and scarring 4. Improves quality of life and reduces work loss **Mnemonic:** **SUPPRESS** = **S**tart oral acyclovir → **U**se 400 mg BD → **P**revent recurrence → **P**rotect cornea → **R**educe episodes → **E**nable long-term control → **S**afe and evidence-based → **S**ustain for 6–12 months [cite:Kanski 9e Ch 4] 
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