This patient with a history of herpes keratitis presents with blurred vision. The slit-lamp examination shows corneal oedema and mild anterior chamber reaction as above.

Is topical steroid contra-indicated in this patient?

Answer
No. The Herpetic Eye Disease Studies (HEDS) on the efficacy of
topical steroids in stromal keratitis in patients who are on topical 
trifluridine found that compared with placebo, steroid therapy reduced 
the risk of persistent or progressive stromal keratouveitis. There was no increased risk of recurrent of ocular HSV.

Does oral acyclovir prevent further episode?

Answer
Yes. While the Herpetic Eye Disease Studies found that oral acyclovir
when started during acute epithelial keratitis does not prevent stromal 
disease. Oral acyclovir 400mg twice daily for a year after the onset of 
active HSV significantly prevent recurrences of both epithelial and stromal HSV.
 

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