YES NOT SURE

YES NO

YES NO

ZIRGAN® (GANCICLOVIR OPHTHALMIC GEL) 0.15% DOSING AND FOLLOW-UP

ZIRGAN® (ganciclovir ophthalmic gel) 0.15% is a topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers). ZIRGAN should be applied five times daily (or every three hours while awake). The initial dosing should be continued for the duration of time required for the corneal ulcer to heal. (Healing can be defined as an absence of fluorescein uptake at the ulcer site; this typically, but not invariably, occurs within 1 week.) Once the ulcer has healed, the ganciclovir dose should be reduced to three times daily and continued for 7 days thereafter.1

Patients should be advised to avoid wearing contact lenses while experiencing signs and symptoms of HK and during the course of treatment with ganciclovir gel.1

Patients should be reexamined 1 to 2 weeks following initiation of treatment or sooner at the discretion of the clinician. If the diagnosis is in question, or if the ulceration is severe, follow-up as early as 48 to 72 hours to assess initial response to treatment may be appropriate.

REFERENCES
  1. Zirgan (ganciclovir ophthalmic gel) 0.15% prescribing information. Tampa, FL: Bausch & Lomb, Inc; 2010.

INDICATION

ZIRGAN® is a topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers).

IMPORTANT RISK INFORMATION ABOUT ZIRGAN®

• ZIRGAN® is indicated for topical ophthalmic use only.
• Patients should not wear contact lenses if they have signs or symptoms of herpetic keratitis or during the course of therapy with ZIRGAN®.
• Most common adverse reactions reported in patients were blurred vision (60%), eye irritation (20%), punctate keratitis (5%), and conjunctival hyperemia (5%).
• Safety and efficacy in pediatric patients below the age of 2 years have not been established.

Click here for complete prescribing information for Zirgan

BEFORE YOU TREAT:
WARNING - AVOID TOPICAL STEROIDS

If the diagnosis is in question, empirical treatment should NOT include corticosteroids, as this may aggravate infections caused by HSV, fungus, Acanthamoeba, or other pathogens.

THE ROLE OF TOPICAL AND ORAL ANTIVIRALS IN TREATING HERPETIC KERATITIS

A RECOMMENDED TREATMENT FOR EPITHELIAL HERPETIC KERATITIS

ALTERNATIVE TREATMENT OPTIONS

As the only selective antiviral formulated for topical application, ZIRGAN® (ganciclovir ophthalmic gel) 0.15% is a recommended first-line treatment for dendritic HK; alternatives include trifluridine 1% ophthalmic solution or an oral antiviral agent.1

Trifluridine 1% ophthalmic solution is a reasonable alternative choice for the acute treatment of HK, particularly when low medication cost is a top priority. Trifluridine is an example of a non-selective antiviral. Non-selective antiviral agents inhibit not only virus reproduction but also cellular DNA synthesis in uninfected cells. As such, non-selective antiviral agents can interfere with wound healing and contribute to ocular surface toxicity. Associated complications are rare, but can be serious when viral infection produces large corneal ulcers that require significant cell division to heal.2

Trifluridine is preserved with thimerosal, a mercury-based preservative. Trifluridine should not be used for longer than 21 days due to the potential for ocular toxicity.3

Although used in some clinics, oral antiviral monotherapy for the treatment of uncomplicated epithelial HK has become less attractive since the development of effective selective topical antiviral treatment. Trials comparing the use of oral and topical antivirals in the treatment of HK are lacking, and unlikely to be performed as topical therapy has been shown to be effective and well tolerated.1 Patients who are unable to tolerate topical treatment, such as those who have undergone corneal grafting, may be candidates for oral antiviral treatment (with acyclovir, valacyclovir, or famciclovir), which was shown to be as effective as topical treatment in at least one study.4

REFERENCES

  1. Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database of Systematic Reviews 2010, Issue 12.
  2. Kaufman HE. Part three: the historical perspective. Advances in the management of ocular herpetic disease. Candeo Clinical/Science Communications. 2011;16-18.
  3. Viroptic Ophthalmic Solution, 1% Sterile (trifluridine ophthalmic solution) Archived Drug Label. Available at: http://dailymed.nlm.nih.gov/dailymed/ archives/fdaDrugInfo.cfm?archiveid=7007. Accessed on 9/4/12.
  4. Collum LMT, McGettrick M, Akhtar J, et al. Oral acyclovir (Zovirax) in herpes simplex dendritic corneal ulceration. Br J Ophthalmol.1986;70:435-8.

ADJUNCTIVE TREATMENT OPTIONS

Systemic antiviral medication may be used as an adjunct to topical treatment of HK, although evidence for added benefit over topical treatment alone is lacking. Select patients may benefit from adjunctive oral antiviral therapy, such as those with large dendritic lesions, geographic lesions, significant iritis, or who are immunocompromised. Patients with comorbid HSV dermatoblepharitis warrant adjunctive treatment with systemic antiviral therapy. Recommended therapies include oral acyclovir (400 mg five times daily) or valacyclovir (500 mg three times daily).1

REFERENCES

  1. Wilhelmus KR. Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database of Systematic Reviews 2010, Issue 12.


IMPROVED

Continue ZIRGAN® (ganciclovir ophthalmic gel) 0.15% 5x daily until healed.

Patients who are improved but not fully healed should continue on ganciclovir gel: one drop in the affected eye given five times daily until the ulcer is healed. Once healed, the dosage may be reduced to three times daily for an additional 7 days.1

REFERENCES

  1. Zirgan (ganciclovir ophthalmic gel) 0.15% prescribing information.
    Tampa, FL: Bausch & Lomb, Inc; 2010.

INDICATION

ZIRGAN® is a topical ophthalmic antiviral that is indicated for the treatment of acute herpetic keratitis (dendritic ulcers).

IMPORTANT RISK INFORMATION ABOUT ZIRGAN®

• ZIRGAN® is indicated for topical ophthalmic use only.
• Patients should not wear contact lenses if they have signs or symptoms of herpetic keratitis or during the course of therapy with ZIRGAN®.
• Most common adverse reactions reported in patients were blurred vision (60%), eye irritation (20%), punctate keratitis (5%), and conjunctival hyperemia (5%).
• Safety and efficacy in pediatric patients below the age of 2 years have not been established.

Click here for complete prescribing information for Zirgan

HEALED

Continue ZIRGAN® (ganciclovir ophthalmic gel) 0.15% 3x daily for 7 days.

Patients should be reexamined 1 to 2 weeks following initiation of treatment, or sooner at the discretion of the clinician.

Typically, healing is first evident at the sites of actively replicating virus in the terminal bulbs of the ulcer; however, various patterns of healing may be observed. Patients who are responding well to therapy will have substantial reduction in the size of the ulcer or full reepithelialization at follow-up. Once the ulcer is healed, patients should continue on ganciclovir gel at a reduced dosing frequency of one drop in the affected eye given three times daily for an additional 7 days.1

REFERENCES

  1. Zirgan (ganciclovir ophthalmic gel) 0.15% prescribing information.
    Tampa, FL: Bausch & Lomb, Inc; 2010.

 

NOT IMPROVED

Most patients respond well to topical antiviral therapy; however, occasionally follow-up examination will reveal a lack of improvement or progression of the ulcer. This may be attributable to factors related to the disease, the host, the treatment, or a combination of factors. Considerations in such cases include lack of patient compliance with treatment or an inaccurate diagnosis. If one is confident that neither the diagnosis nor compliance is in question, referral to a corneal specialist may be warranted to confirm the diagnosis, rule out antiviral resistance, and/or modify the treatment regimen.

ASSESS COMPLIANCE

Most patients respond well to topical antiviral therapy; however, occasionally follow-up examination will reveal a lack of improvement or progression of the ulcer. This may be attributable to factors related to the disease, the host, the treatment, or a combination of factors. A consideration in such cases is lack of patient compliance with treatment.

CONSIDER ALTERNATIVE DIAGNOSIS

Most patients respond well to topical antiviral therapy; however, occasionally follow-up examination will reveal a lack of improvement or progression of the ulcer. This may be attributable to factors related to the disease, the host, the treatment, or a combination of factors. A consideration in such cases is an inaccurate diagnosis.

CONSIDER REFERRAL

Most patients respond well to topical antiviral therapy; however, occasionally follow-up examination will reveal a lack of improvement or progression of the ulcer. This may be attributable to factors related to the disease, the host, the treatment, or a combination of factors. If one is confident that neither the diagnosis nor compliance is in question, referral to a corneal specialist may be warranted to confirm the diagnosis, rule out antiviral resistance and/or modify the treatment regimen.



 

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