Second opinion on herpes simplex keratitis treatment

The question:

A 47-year-old male patient explains that he has recently been diagnosed with herpes simplex keratitis at the practice down the road. He was prescribed an acyclovir gel, which he has been using for six days with no improvement. He is not satisfied with the service he received, which is why he is seeking a second opinion. How would you manage? 

OT’s panel says...

Ankur Trivedi: I would want to start by ascertaining as many of the details and facts as possible. How often per day was the patient asked to use the gel, and has he done so? Does he have any previous history of similar episodes?

I would also be keen to ascertain which exact aspect he is reporting no improvement on – visual acuity, pain or discomfort, or some other parameter?

It would be very useful to know how the issue was at presentation, so I would ask permission to make contact with the independent prescribing optometrist that he saw originally, to allow me to get some idea of that.

Kevin Wallace: In the first instance, I would encourage the patient to go back to the practice and explain what he has told me. It is always best to continue with the care provider, especially as I don’t currently know what his presenting symptoms were.

When treating any eye condition, I tell the patient that if it is not doing what I expect it do (and generally that is getting better), and particularly in a more serious eye condition such as this, I want to see them again promptly.

I would be worried if this patient said that their eye was still painful and photophobic. If they didn’t want to go back to the previous practice, they would need to be examined again in order to gain confirmation that the initial diagnosis was correct.

As Ankur said, it is important to verify that they have been using the medication appropriately. Depending on the circumstances and the findings, we can then modify their treatment as necessary.

We all have to be very careful in using steroids for herpetic eye disease, but with appropriate anti-viral cover they are sometimes necessary. As always, it is important to consider whether you should treat this patient or whether you should seek advice from your local eye department – particularly because a delay of a few days in receiving the appropriate treatment can lead to a worse outcome.

We all have to be very careful in using steroids for herpetic eye disease, but with appropriate anti-viral cover they are sometimes necessary

 

Ceri Smith-Jaynes: I totally agree with Kevin and Ankur – if one of my patients wasn’t improving from my treatment plan, or they weren’t happy with some aspect of the service, I’d wish to know. Feedback – even if it hurts the ego – is a means to improvement.

Locally, I feel independent prescribers need to work together and support one another. The fact the treatment isn’t working, after six days, is a way of forming a new diagnosis. I have treated just a few simple, epithelial, herpes simplex keratitis cases and they’ve healed beautifully with ganciclovir gel; it is much cheaper and more gel-like, so a bit nicer to use than aciclovir ointment, with similar effectiveness.

We need to consider some differential diagnoses:

• It is herpes simplex, but in the stroma or endothelium? College of Optometrists Clinical Management Guidelines list this as A1 referral to ophthalmology
• That the lesion the first optometrist saw got infected by bacteria
• Acanthamoeba keratitis: contact lens wearers with dendritic ulcers are another A1 referral to ophthalmology
• Is it another organism, for example, fungal keratitis? This would definitely be beyond my scope of practice
• Medicamentosa, which is less likely: the lesion got better, but the patient has a sensitivity to the paraffin in the ointment
• Perhaps a bit of a long-shot, but is it actually filamentary keratitis, which looked like dendrites on presentation?

If you are unsure about how to manage a scenario in practice, contact the AOP’s regulation team by email.