Review of Cornea






Become a fan on Facebook Follow us on Twitter
Table of Contents

Adenoviral Infections: Take Charge of EKC

Staff

9/8/2009

There is indeed an excellent, highly effective, easily applied and very cost-effective treatment for acute EKC. To maximize therapeutic response in viral infections, initiate therapy early in the disease process.

Dear Drs. Melton and Thomas,

I am an O.D. in a seven-doctor ophthalmology/optometry practice. The majority of my patients are within the realm of corneal disease, as I work closely with our corneal specialist.

I was intrigued when I read your recent article in the November 2008 issue of Review of Optometry, regarding the use of 5% Betadine to treat acute EKC. From December 2006 through March 2007, we had an outbreak of a very aggressive strain of EKC among our three offices. While we did see patients who were obviously through our office (we seriously amended our cleaning and disinfecting protocols), we also saw patients new to our office with EKC. All in all, we saw close to 275 patients during that time with EKC. Yet, in my research, I never found anything like your protocol.

Upon reading the recent article, I decided I would implement treatment on the next acute EKC patients that I saw in the office. I treated four patients the month of January, one of whom was a technician, two confirmed with the RPS test. All had improvement of their symptoms within two days, and resolution within four to five days. None developed infiltrates or membranes.

I find it curious that most of optometry and ophthalmology have not embraced this treatment. I spoke with a colleague regarding the treatment and he was not impressed. His response was that they will get better in a week anyway. Most of the doctors (M.D.s) within my practice had never heard of this treatment, including one who recently completed his fellowship in anterior segment. I can tell you in 12 years of practicing, I have never seen true EKC clear up in a week. These patients are miserable, uncomfortable, and unable to work. Perhaps after seeing nearly 200 patients during that outbreak has hyper-sensitized me.

I work closely with a corneal specialist. He shares my opinion that this is not well embraced and that extensive research into some obscure ophthalmology journals is required to even find mention of off-label 5% Betadine use to treat EKC.

As primary care providers, optometry needs to embrace this treatment and put it into practice. All that is required is a careful history and slit lamp biomicroscope, as well as some 5% Betadine. Again, thank you for your time and for the fascinating article.

To further illuminate the dismal awareness of this excellent, offlabel, medical treatment, let’s look at the following two quotes from the contemporary medical literature:

“Unfortunately, no effective treatment has been found for viral conjunctivitis.”

— Ohnsman CM. Study looks at exclusion of students with conjunctivitis from school. Ocular Surgery News. 2007 April 15;25(8):160-3.

“Since the initial description of epidemic adenoviral ocular infections in Austria in 1889 until the present day, no effective drug to treat such patients has been found. Today, acute adenoviral ocular infections (epidemic keratoconjunctivitis, follicular conjunctivitis, and pharyngeal conjunctival fever) remain among the most common external ocular viral infections seen clinically worldwide … There are 51 serotypes of adenovirus, of which approximately one-half have been shown to cause ocular disease. The American Academy of Ophthalmology Preferred Practice Pattern proposes symptomatic treatment for these infections and the use of topical steroids to reduce scarring in severe cases of adenoviral keratoconjunctivitis with marked chemosis or lid swelling, epithelial sloughing, or membranous conjunctivitis. Lacking an effective Food and Drug Administration- approved antiviral, clinicians recognize the continuing need to develop a drug to reduce patient morbidity, to reduce the extent of or entirely prevent the formation of vision-altering subepithelial infiltrates, to reduce lost time from school or work, and to reduce or prevent the transmission of ocular infections within households, communities, and medical facilities.”

— Romanowski EG, Gordon YJ. Update on antiviral treatment of adenoviral ocular infections. Am J Ophthalmol. 2008 Nov;146(5): 635-7.

The good news is there is indeed an excellent, highly effective, easily applied and incredibly cost-effective treatment therapy for acute EKC. The key to a maximal therapeutic response in viral infections is to initiate therapy early in the course of the disease process.

Let’s look at the clinical features of acute EKC. Almost all of these patients present with a history of acute redness starting in one eye, and spreading to the fellow eye in two to three days. A watery discharge is a constant feature. A palpable preauricular node is commonly detected (if one feels for it) on the side of the initially infected eye. In more advanced cases, the bulbar conjunctiva can demonstrate multiple petechial hemorrhages, most commonly seen superiorly. Bacterial conjunctivitis can have variably expressed microvascular injection of the conjunctiva, and evident mucopurulent discharge. Only in “hyperacute” bacterial conjunctivitis is there evident preauricular lymph adenopathy. If diagnostic certainly is elusive, the RPS Adeno Detector (www.rpstests. com) may be helpful.

When we encounter a patient with moderate to advanced EKC, we generally treat them via the following “Melton-Thomas EKCBetadine Protocol”:

  1. By history, rule out any allergy or sensitivity to iodine, the molecular backbone of Betadine.
  2. Instill a drop of 0.5% proparacaine, as Betadine (like tropicamide) stings upon instillation.
  3. Betadine can cause mild stippling to the corneal epithelium resulting in marked stinging. So instill a drop or two of a topical NSAID.
  4. Instill four to five drops of Betadine onto the eye.
  5. Ask the patient to gently close the eyes and roll them around to ensure thorough distribution of the Betadine across the ocular surfaces.
  6. After one minute, lavage out the Betadine (to avoid any unnecessary toxicity and discoloration of the tissues) with any sterile ophthalmic irrigating solution.
  7. Just for good measure, instill another drop or two of the NSAID (or even proparacaine if the patient has any discomfort).

We have now essentially eliminated the adenoviral load; but of course, we’ve done nothing for the secondarily inflamed conjunctival tissues. To address the inflammatory component, prescribe Lotemax q.i.d. for four days.

Between the two of us, we have used this procedure more than 200 times now and find it enormously helpful for our patients with acute EKC. More importantly, we have queried audiences all across the country, and have yet to find any optometrist who reports anything other than success with use of this protocol.

Antiviral Infections

In addition to EKC adenoviral infection, there are two additional viral infections that are clinically important: herpes simplex and varicella zoster.

We should be well prepared to diagnose and competently intervene therapeutically on behalf of patients with diseases caused by these viruses.

Herpes Simplex Virus

Herpes simplex viruses (HSV) are responsible for nearly 50,000 new and recurring cases of HSV keratitis each year in the United States.1 HSV almost exclusively manifests as dendritiform or geographic epithelial keratitis.

Fortunately, we have a tried-and-true, FDAapproved medicine to kill the herpes simplex virus, available both generically as trifluridine 0.1% ophthalmic solution and by its original brand name of Viroptic (Monarch Pharmaceuticals). Treatment is usually straightforward: one drop to the affected eye every two hours (while awake) for four to five days, then q.i.d. for four or five more days, depending upon the individual response. Preservative-free artificial tears are the only other eye drops that might be helpful in conjunction with this topical approach.

Then again, many doctors now bypass topical therapy and simply initiate therapy with an oral antiviral, such as 400mg of oral acyclovir five times a day for one week or Valtrex (valacyclovir, GlaxoSmith- Kline) 500mg t.i.d. for one week.

Herpes Zoster (Varicella Zoster) Disease

The head and/or face is the second most common site (after the trunk) for the expression of shingles. More specifically, the ophthalmic (or first) division of the trigeminal nerve is the most common head/face site of expression. Regardless of site, the treatment is uniform: 800mg of acyclovir (ACV) p.o. five times a day for one week.

Patients are commonly sent to eye doctors by internists, dermatologists and family physicians to rule out eye involvement. Sometimes patients with head/face shingles simply present first to an eye doctor for care. In either case, it is essential to assess the global tissues, looking specifically for anterior uveitis and/or an inflammatory keratitis, as these are by far the most common eye manifestations of the VZ virus. The eye itself is involved in approximately half of all ophthalmic division cases.2 The rest are simply dermatologic cases. If the eye is involved, it is always an expression of inflammation, and is usually quickly controlled with the aggressive use of a potent corticosteroid such as Lotemax or Pred Forte.

Since the herpes viruses are neurotrophic, afferent sensation can be perturbed for many months after successfully treating the initial zoster disease. Such post-herpetic neuralgia is probably best treated by a primary-care physician or dermatologist. Treatment is generally accomplished with a tricyclic antidepressant, such as amitriptyline, and analgesics.

For cases of chicken pox occurring in children over the age of two and generally weighing over 40lbs., the FDA’s and CDC’s recommended dosage of ACV is up to 800mg q.i.d. for one week, depending upon the weight of the patient. We think this strongly demonstrates the safety of these antivirals.

There are three oral antivirals currently available. Besides acyclovir (Zovirax, GlaxoSmithKline), there is valacyclovir (Valtrex, GlaxoSmithKline) and famciclovir (Famvir, Novartis). Valtrex’s zoster dosage is 1,000mg t.i.d. for one week. For herpes simplex, it is dosed at 500mg t.i.d. for one week. Famvir’s zoster dosage is 500mg t.i.d. for one week; for herpes simplex, it is dosed at 250mg t.i.d. for one week. All three drugs are minimally biologically active until they are activated via viral thymidine kinase phosphorylation. This wonderfully unique mechanism of viral kinase activation is the mechanism that makes this class of oral antivirals so safe, yet so highly effective.

These medicines are maximally effective when instituted within the first three days of disease manifestation; however, they still render a positive therapeutic effect when used even five, six or seven days into the disease event. Keep this in mind so that patients will not be denied proper medical care.

One area of caution with regard to these oral antivirals is renal disease. Since these drugs are excreted via the kidneys, make sure there is no known kidney disease. If there is kidney function impairment, then call the patient’s nephrologist or primary care physician to learn the patient’s creatinine clearance value. You should then have a telephone visit with a pharmacist or the patient’s physician who, via a quick and simple computer program, will be able to calculate the appropriate antiviral dosage for your patient based upon this value. It’s very straightforward.

In summary, there are excellent, safe and highly effective drugs available to treat viral diseases afflicting the human eye: 5% ophthalmic Betadine for EKC, trifluridine (or oral antivirals) for epithelial herpes simplex, and oral antivirals for shingles and/or chicken pox. When properly applied, these drugs bring rapid relief to nearly all patients.

  1. Liesegang TJ. Herpes simplex virus epidemiology and ocular importance. Cornea 2001 Jan;20(1):1-13. Review.
  2. Pavan-Langston D. Herpes zoster ophthalmicus. Neurology 1995 Dec;45(12 Suppl 8):S50-1.


Search on This Topic            Back to Supplement  
Optometric Retina Society

Optometric Retina Society Newsletter aims to provide clinical updates in retinal disease for primary care optometrists. As part of this mission, the ORS organizes both annual meetings and a quarterly e-newsletter, through which the latest research and clinical findings are presented to attendees and readers.

To subscribe to the Optometric Retina Society quarterly e-newsletter and receive it via e-mail, click here.

Optometric Glaucoma  Society

Optometric Glaucoma Society Newsletter strives to promote excellence in the care of patients with glaucoma through professional education and scientific investigation. Its objectives are to promote the education of health care professionals, to promote glaucoma research, to make this information accessible to health care professionals and the public, and to establish collaboration with other professional organizations.

To subscribe to the E-Journal of the Optometric Glaucoma Society and receive it via e-mail, click here.

Optometric Glaucoma  Society

Optometric Physician Newsletter is a weekly e-journal edited by Art Epstein, O.D. It began in 2001 and discusses current optometric issues, research and industry news.

To subscribe to OP and receive it via e-mail, click here.

Classifieds | Patient Handouts | Optometric Study Center | Editorial Staff | Business Staff | Media Kit | Contact | Privacy Policy | Subscribe