Prophylactic High-Dose Oral Aciclovir For The Prevention Of Recurrent Herpes Simplex Keratitis Following Corneal Endothelial Transplant

To report a case of prophylactic high-dose oral aciclovir for a patient with a high-risk herpetic corneal scar undergoing corneal endothelial transplant.

James Paget University Hospital, Great Yarmouth, UK.

A 66-year-old male with a history of recurrent right herpes simplex kerato-uveitis was managed with long-term high-dose oral aciclovir over 27 months.

His complex ocular history included corneal thinning and scarring with a neuropathic cornea secondary to previous herpetic keratitis, as well as Fuchs’ endothelial dystrophy, prior chelation of band keratopathy, right amblyopia, and a known steroid response to topical dexamethasone.

At initial presentation, corneal endothelial transplant was delayed, given the high risk of corneal transplant rejection and failure. Medical management was optimised with oral Aciclovir (800mg five times a day), topical dexamethasone and sodium chloride ointment. He was listed for right superficial keratectomy combined with phaco. Postoperatively, he had an epithelial defect which was slow to heal, likely due to reactivation. Following this, he was listed for left DMEK, after which the epithelium healed quickly.

Over the treatment course, the patient remained quiescent with no further episodes of herpetic keratitis. Corneal integrity was maintained without further progression of thinning or scarring, and no additional graft rejection episodes were observed. Furthermore, despite his history of steroid response, intraocular pressure remained controlled with careful monitoring, allowing for effective anti-inflammatory management when needed.

This case highlights the efficacy of high-dose aciclovir in the long-term management of recurrent herpetic keratitis, particularly in a patient with a complex ocular history undergoing corneal transplantation. The therapy successfully minimised the risk of recurrence and graft failure, underscoring the importance of antiviral prophylaxis in high-risk individuals. High-dose aciclovir remains a valuable strategy for preventing complications in recurrent herpetic eye disease, particularly in patients with prior grafts or corneal involvement.