Supervised Reduction Protocol for Management of Herpetic Stromal Keratitis

Purpose: Herpetic stromal keratitis (SK) caused by herpes simplex virus (HSV) or varicella zoster virus (VZV) can cause sight-threatening corneal scarring. Given high recurrence rates of herpetic SK with steroid reduction and limited consensus on treatment duration, we examine outcomes of an approach we term the supervised reduction protocol (SRP). Methods: Among 162 patients with ocular HSV or VZV evaluated between September 2016 and June 2025, 53 had SK managed with SRP. Under the SRP, patients underwent frequent slit-lamp evaluation allowing for early detection and management of stromal inflammation. Topical steroids and systemic antivirals were only reduced under direct physician supervision to ensure quiescence before further reduction. Results: Thirty-three patients had HSV SK and 20 had VZV SK. The median time from diagnosis to quiescence was 72 days [interquartile range (IQR) 35.5–145)] for HSV SK and 51 days (IQR 24.5–77) for VZV SK. The median time from quiescence to recurrence of clinical SK was 63 days (IQR 44–250) for HSV SK and 175 days (IQR 124.3–358) for VZV SK. Most recurrences occurred after steroid discontinuation; none occurred on QID dosing. Recurrence rates were 33% (HSV) and 50% (VZV), and most were asymptomatic at the time of recurrence (73% HSV, 50% VZV). Visual acuity remained stable from initial diagnosis to quiescence. Conclusions: Close follow-up under the SRP allows for detection and treatment of early, often asymptomatic recurrences before they progress to symptomatic or vision-threatening disease. This was a single-site retrospective study of one physician's outcomes; thus, these findings do not establish that SRP is superior to others management approaches. Prospective, multisite comparative effectiveness studies are needed to validate the role of SRP for herpetic SK.