Original Title: Guide usage optimal: traitement des atteintes oculaires à herpès simplex

Authors' objectives: In light of the new regulation concerning the drugs that an optometrist can prescribe, and with a view to supporting and harmonizing primary care health professional practice, the Ordre des optométristes du Québec (OOQ) and the Collège des médecins du Québec (CMQ) asked the Institut national d’excellence en santé et en services sociaux (INESSS) to produce an optimal use guide (OUG) on the treatment of herpes simplex eye disease. The objective of this report is to present all the data gathered for the purpose of this project and the argument in support of the clinical recommendations that led to the production of the optimal use guide on antivirals in the treatment of blepharitis, blepharoconjunctivitis and dendritic epithelial keratitis caused by the herpes simplex virus (HSV).

Authors' results and conclusions: RESULTS: Information on the clinical presentation of HSV eye disease is generally consensual in nature and well known to clinicians. As a general rule, there is, or is not, pain (varying severity), mainly unilateral involvement, possibly blepharoconjunctivitis with eyelid lesions and a follicular conjunctival reaction (redness), and sometimes a palpable preauricular lymph node. Skin involvement manifests as clusters of vesicles, papules and pustules a few millimetres in size on an erythematous base that are identical to those of an individual herpes zoster lesion and usually preceded by tingling instead of pain. The clustering of vesicles, papules and pustules, which do not follow a dermatome and which can cross the median line, and the recurring nature are often consistent with HSV eye disease. The first episode can manifest solely as eyelid involvement, but there will generally be corneal involvement during the recurrences. All the structures of the eye may then be affected (slit lamp evaluation mandatory). Knowledge of the warning signs and symptoms and their recognition by the clinician during the evaluation are important for ensuring that the patient is quickly referred to a professional qualified to perform a slit lamp evaluation and to determine which layer of the cornea is affected. Herpes simplex lesions can be mistaken for other lesions. Stromal and endothelial layer involvement and geographical ulcers (in contrast to dendritic epithelial keratitis) should be monitored by a specialist. It is therefore important that health professionals determine the limits of their practice in terms of performing the activities reserved for them by the statute or a regulation and to refer the patient to the appropriate specialist when his or her condition is beyond their scope of practice. To equip primary-care clinicians for their decision-making, and given the seriousness, the potential complications and the practice settings, benchmarks for acceptable wait times for a patient to be seen by a professional qualified to perform a slit lamp evaluation have been proposed, based on the documents and the experience of the experts consulted. It was determined that an adult who presents only with vesicles or eyelid margin lesions but no warning signs or symptoms should, if need be, undergo a slit lamp evaluation by a qualified professional, but only if the clinician considers this necessary. If, in addition to eyelid margin lesions, there is conjunctivitis-like redness, the patient should undergo a slit lamp evaluation performed by a qualified professional within three days of its appearance to assess the corneal involvement and its severity, and the wait time should be less than 24 hours if there are warning symptoms and signs. If the patient is referred to an optometrist, the latter may refer the patient to an ophthalmologist if the case is beyond the activities that he or she can perform under the statute or a regulation. However, these wait times do not apply to patients with an immunocompromised state or to children with HSV eye disease. Rather, they should be referred at once to an ophthalmologist for an appointment within 24 hours for children and between 24 and 48 hours for patients with an immunocompromised state. Although herpes simplex eye disease resolves spontaneously, generally within two weeks, antiviral therapy, topical or oral, may reduce its severity and duration and the viral replication, control the inflammation and prevent complications, as shown by the scientific and experiential data. The scientific literature data do not show a statistically significant difference between the oral form and the topical form of the treatment, both being effective in cases of herpetic keratitis. To limit corneal damage, it is advisable to prescribe an antiviral as soon as possible if the clinical presentation is consistent with herpes simplex eye disease, even if a specialist consultation request has been initiated. Despite the adjustment for renal function, the safety profile of the three oral antivirals is very good. The choice is guided by the simplicity of the dosing regimen of valacyclovir and famciclovir. In children, valacyclovir could be recommended because of its better absorption and its ease of use via oral administration (per os) as a magistral solution or as tablet fractions based on the calculated weight. In light of clinical experience and information gleaned from the publications selected, including the product monographs, it was decided to include a reminder concerning the use of topical corticosteroids. They are contraindicated in the initial treatment of HSV epithelial keratitis because there is a risk of exacerbating the damage and causing stromal keratitis with a risk of permanent and more serious sequelae. CONCLUSION: For timely management of patients who present with symptoms and signs indicative of HSV eye disease, primary-care health professionals should take care to use a clinical approach that will enable them to identify the ocular involvement and to thus choose the appropriate treatment, to recognize the warning signs and symptoms, and to decide whether or not there is an urgent need to refer the patient to an ophthalmologist. The OUG presents the best practices, both in terms of clinical evaluation, treatment and follow-up. It is intended as a support tool for primary-care health professionals, but it is not a substitute for clinical judgment, for the patient’s condition can become complicated and cause permanent sequelae. However, clinicians have effective antivirals at their disposal, whose rapid onset of action is all-important.

Authors' methods: This OUG is based on the best available scientific data evaluated by the authors of clinical practice and other guidelines, and on recent systematic reviews concerning herpes simplex eye disease. These data were enriched with organizational and legislative contextual elements specific to Québec, information on available drugs that are or are not covered by Québec’s public prescription drug insurance plan, and the experiential knowledge provided by different Québec clinicians and experts who collaborated in this project. The MEDLINE, EBM Reviews and Embase databases were systematically searched for the relevant clinical practice and other guidelines, consensus conference reports and systematic reviews. In addition, a grey literature search was conducted by consulting the websites of the Guidelines International Network and the National Guideline Clearinghouse and those of recognized learned societies in the field of ocular health. The literature search was limited to clinical practice guidelines published between 2012 and 2017 in French or English. The official product monographs for Health Canada-approved antivirals were consulted as well.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/outils-cliniques/outils-cliniques/outils-par-types/aide-a-la-decision-dialogue-patient-aide-memoire-appropriation/outils/zona-ophtalmique-soins-oculaires.html#c6576

Year Published: 2018

URL for published report: https://www.inesss.qc.ca/outils-cliniques/outils-cliniques/outils-par-types/aide-a-la-decision-dialogue-patient-aide-memoire-appropriation/outils/zona-ophtalmique-soins-oculaires.html#c6576

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en santé et en services sociaux