In HSV keratitis treatment, which corticosteroid is added for stromal or endothelial involvement?

In HSV keratitis treatment, which corticosteroid is added for stromal or endothelial involvement?

• A. Prednisolone acetate 1% 6-8x/day with extended taper
• B. Fluorometholone
• C. Loteprednol etabonate
• D. Dexamethasone

Answer: (A)

When HSV keratitis involves the deeper cornea (stroma) or endothelium, the inflammation is immune-mediated and requires a potent anti-inflammatory drug added after the epithelial disease has stabilized. The best choice is a strong topical corticosteroid that penetrates the cornea well, used at a high frequency initially to rapidly control stromal edema and keratic precipitates, followed by an extended taper to prevent rebound inflammation and minimize long-term steroid side effects. Prednisolone acetate 1% is the standard because of its potency and corneal penetration, allowing effective suppression of stromal inflammation when started at 6–8 times daily and then tapered slowly. Softer steroids like fluorometholone or loteprednol etabonate are less sufficient for stromal involvement, and while dexamethasone is potent, prednisolone acetate remains the preferred choice for this scenario due to its proven efficacy in reducing stromal inflammation with a manageable taper plan. Always continue antiviral therapy alongside and monitor intraocular pressure during the course.

When HSV keratitis involves the deeper cornea (stroma) or endothelium, the inflammation is immune-mediated and requires a potent anti-inflammatory drug added after the epithelial disease has stabilized. The best choice is a strong topical corticosteroid that penetrates the cornea well, used at a high frequency initially to rapidly control stromal edema and keratic precipitates, followed by an extended taper to prevent rebound inflammation and minimize long-term steroid side effects.

Prednisolone acetate 1% is the standard because of its potency and corneal penetration, allowing effective suppression of stromal inflammation when started at 6–8 times daily and then tapered slowly. Softer steroids like fluorometholone or loteprednol etabonate are less sufficient for stromal involvement, and while dexamethasone is potent, prednisolone acetate remains the preferred choice for this scenario due to its proven efficacy in reducing stromal inflammation with a manageable taper plan. Always continue antiviral therapy alongside and monitor intraocular pressure during the course.