Antiviral therapy after penetrating keratoplasty for herpes simplex keratitis
A. L. Moyes, A. Sugar, D. C. Musch and R. D. Barnes
W. K. Kellogg Eye Center, Department of Ophthalmology, Ann Arbor.
OBJECTIVE: To assess the efficacy of prophylactic topical antiviral therapy
after penetrating keratoplasty for herpes simplex keratitis in the
postoperative period and during the treatment of allograft rejection
episodes with topical steroids. We used these data to make predictions of
the sample size required to perform a prospective study of prophylactic
oral acyclovir in the postoperative period. DESIGN: Retrospective review.
SETTING: A university referral cornea service. PATIENTS: One hundred
thirty-two consecutive penetrating keratoplasties for herpes simplex
keratitis in 119 eyes of 118 patients. Only four grafts were performed in
actively inflamed eyes. INTERVENTIONS: Sixty-six (52%) of the grafts
performed in quiescent eyes received prophylactic postoperative topical
antiviral treatment, three (2%) received oral acyclovir, and 59 (46%)
received no antiviral therapy. The mean (+/- SD) duration of antiviral
therapy was 12.8 +/- 22.5 months. MAIN OUTCOME MEASURES: Herpetic
recurrence, allograft rejection episodes, and graft failure. RESULTS:
Multivariate analysis showed that early antiviral use was associated with a
decreased risk of herpes simplex keratitis recurrence (relative risk [RR] =
0.44; 95% confidence interval [CI], 0.21 to 0.94; P = .007) and allograft
rejection (RR = 0.43; 95% CI, 0.25 to 0.75; P = .002). Graft failure was
associated with herpetic recurrence within the first year (RR = 2.25; 95%
CI, 1.09 to 4.64; P = .001) and allograft rejection episodes (RR = 2.56;
95% CI, 1.20 to 5.26; P = .003). Using these data, a prospective trial of
postoperative oral acyclovir would require between 59 and 112 patients per
group. CONCLUSIONS: Postoperative prophylactic antiviral treatment is
associated with decreased rates of herpes simplex viral keratitis
recurrence and allograft rejection. Early recurrence is associated with an
increased risk of graft failure. A prospective study of postoperative oral
acyclovir would require a multicentered approach.
