Skip to content
How It Works
Explore
Resources Ask a Question
Who It's For
Patients
Decode results, prep for appointments, weigh options.
Caregivers & advocates
Carry the research load for someone you love.
Providers & clinicians
Resources for patients in your practice.
Log In Ask a Question
PubMed This is a summary of 18 peer-reviewed journal articles Updated
Ophthalmology

Life After the Flare: Prevention and Long-Term Health

At a Glance

To prevent HSV stromal keratitis from returning, taking daily low-dose oral antivirals like acyclovir or valacyclovir can cut your recurrence risk in half. Long-term care also requires close monitoring by an ophthalmologist for medication side effects like high eye pressure and cataracts.

Surviving an acute episode of HSV stromal keratitis (HSK) is a major milestone, but management does not end when the redness fades. Because the herpes virus remains dormant in your nerves for life, long-term care focuses on two main goals: preventing future flare-ups and managing the side effects of the medications that saved your sight [1][2].

Reducing Recurrence: The 50% Rule

The most significant finding from the Herpetic Eye Disease Study (HEDS) II is that long-term prevention works. The study proved that taking a low-dose oral antiviral (like acyclovir) daily for one year reduces the risk of any type of herpes eye infection returning by approximately 50% [3][4].

  • Medication Options: Most patients take acyclovir (400mg twice daily) or valacyclovir (500mg once daily). Valacyclovir is often preferred because it only needs to be taken once a day, which helps with long-term “pill fatigue” [5][6].
  • Kidney Health: Because these drugs are processed by the kidneys, your doctor may occasionally order blood tests to ensure your kidney function remains healthy while you are on these medications [7][8].

Identifying Your Triggers

While the virus can wake up for no apparent reason, many patients identify specific “triggers” that precede a flare-up. Importantly, flare-ups often happen without any identifiable trigger at all—do not blame yourself if one occurs despite your best efforts. When triggers are identifiable, they commonly include:

  • UV Exposure: Intense sunlight or tanning beds.
  • Physical Stress: High fever, surgery, or extreme fatigue [9].
  • Atopy: If you have atopic dermatitis (eczema) or severe allergies, you may experience more frequent and more severe HSK recurrences [10][11]. Treating your eczema or allergies can actually help protect your eyes [11].

Long-Term Complications: The “Trade-Off”

The steroids used to treat HSK are essential for preventing scars, but they come with their own set of long-term risks:

  1. Steroid-Induced Glaucoma: Some patients are “steroid responders,” meaning their eye pressure rises when using these drops. High pressure can permanently damage the optic nerve (glaucoma) [12][13].
  2. Cataracts: Long-term steroid use accelerates the clouding of the eye’s natural lens (cataracts), which may eventually require surgery [12].
  3. Neovascularization: Chronic inflammation can cause the body to grow new blood vessels into the clear cornea. These vessels can leak and cause further cloudiness [14].

Life with Corneal Scarring

If repeated infections lead to permanent scarring that blocks your vision, several surgical options are available:

  • DALK (Deep Anterior Lamellar Keratoplasty): This is a “partial-thickness” transplant where only the damaged stromal layer is replaced, leaving your own healthy inner layer (endothelium) intact. It generally has a lower risk of rejection than a full transplant [15][16].
  • PKP (Penetrating Keratoplasty): A traditional full-thickness transplant. While effective, HSK patients must stay on long-term antivirals after surgery to prevent the virus from attacking the new donor tissue [17][2].

Regardless of the surgical path, the first 1 to 3 months after a transplant are the highest-risk period for the virus to return, making close follow-up with your specialist vital [18]. It is also important to set realistic expectations: vision recovery after these surgeries can take several months to a year as the eye heals and adapts to the new tissue.

Return to the Home Page.

Common questions in this guide

Can I prevent herpes eye infections from coming back?
Taking a low-dose oral antiviral medication daily for one year can reduce the risk of herpes eye infections returning by about 50 percent. Many patients take acyclovir or valacyclovir to help keep the virus dormant.
What triggers an HSV stromal keratitis flare-up?
Flare-ups can happen without warning, but common triggers include intense sunlight, physical stress like a high fever, or severe allergies. Treating underlying conditions like eczema can also help protect your eyes.
What are the long-term risks of using steroid eye drops for HSK?
While steroids are essential for preventing corneal scars, long-term use can lead to complications. These include steroid-induced glaucoma from high eye pressure, cataracts, and abnormal blood vessel growth in the cornea.
What happens if my eye develops severe corneal scarring?
If permanent scarring blocks your vision, corneal transplant surgeries like DALK or PKP may be options. After surgery, you will likely need to stay on long-term antivirals to prevent the virus from attacking the new donor tissue.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Am I a good candidate for long-term oral antiviral prophylaxis to cut my recurrence risk in half?
  2. 2.How often should my eye pressure be checked to monitor for steroid-induced glaucoma?
  3. 3.Are there signs of neovascularization (blood vessel growth) in my cornea that we need to address?
  4. 4.If I develop a cataract from my steroid use, how would that affect my HSK management?
  5. 5.Is my corneal scarring severe enough that I should start considering a transplant like DALK?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (18)
  1. 1

    The Characteristics of Herpes Simplex Virus Type 1 Infection in Rhesus Macaques and the Associated Pathological Features.

    Fan S, Cai H, Xu X, et al.

    Viruses 2017; (9(2)) doi:10.3390/v9020026.

    PMID: 28146109
  2. 2

    Impact of Adherence (Compliance) to Oral Acyclovir Prophylaxis in the Recurrence of Herpetic Keratitis: Long-Term Results From a Pediatric Cohort.

    Luccarelli SV, Lucentini S, Martellucci CA, et al.

    Cornea 2021; (40(9)):1126-1131 doi:10.1097/ICO.0000000000002578.

    PMID: 33201055
  3. 3

    Update on the Management of Infectious Keratitis.

    Austin A, Lietman T, Rose-Nussbaumer J

    Ophthalmology 2017; (124(11)):1678-1689 doi:10.1016/j.ophtha.2017.05.012.

    PMID: 28942073
  4. 4

    The need for prolonged antiviral use to prevent recurrences of herpes simplex virus ocular disease: A systematic review.

    Ruiz Sifre L, Bort Martí S, Ruiz García V, Bort Martí ÁR

    Farmacia hospitalaria : organo oficial de expresion cientifica de la Sociedad Espanola de Farmacia Hospitalaria 2025; (49(4)):235-242 doi:10.1016/j.farma.2025.02.005.

    PMID: 40059016
  5. 5

    Herpes Labialis: An Update.

    Leung AKC, Barankin B

    Recent patents on inflammation & allergy drug discovery 2017; (11(2)):107-113 doi:10.2174/1872213X11666171003151717.

    PMID: 28971780
  6. 6

    Valacyclovir Versus Acyclovir for Herpes Simplex Virus Suppression Following Neonatal Infection.

    Olkiewicz HA, Mitchell ML, Ray KM, et al.

    WMJ : official publication of the State Medical Society of Wisconsin 2024; (123(6)):589-592.

    PMID: 39908520
  7. 7

    Association between Concomitant Use of Acyclovir or Valacyclovir with NSAIDs and an Increased Risk of Acute Kidney Injury: Data Mining of FDA Adverse Event Reporting System.

    Yue Z, Shi J, Li H, Li H

    Biological & pharmaceutical bulletin 2018; (41(2)):158-162 doi:10.1248/bpb.b17-00547.

    PMID: 29187701
  8. 8

    Neurotoxicity from acyclovir and valacyclovir in patients undergoing peritoneal dialysis: Still rare, but still present.

    Moyses Neto M, Nakagawa B, Chiozi SZ, et al.

    Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis 2026; 8968608261415988 doi:10.1177/08968608261415988.

    PMID: 41610264
  9. 9

    Physiological oxygen concentration during sympathetic primary neuron culture improves neuronal health and reduces HSV-1 reactivation.

    Dochnal SA, Krakowiak PA, Whitford AL, Cliffe AR

    bioRxiv : the preprint server for biology 2024; doi:10.1101/2024.08.09.607366.

    PMID: 39149301
  10. 10

    Effect of atopic conditions on development and recurrences of infectious keratitis.

    Omatsu Y, Shimizu Y, Haruki T, et al.

    Allergology international : official journal of the Japanese Society of Allergology 2024; (73(3)):445-452 doi:10.1016/j.alit.2024.01.008.

    PMID: 38310042
  11. 11

    Atopic Disease as a Risk Factor for Recurrent Herpetic Keratitis.

    Safir M, Mimouni M

    Microorganisms 2024; (12(1)) doi:10.3390/microorganisms12010220.

    PMID: 38276205
  12. 12

    Stromal Keratitis After Varicella in Children.

    Denier M, Gabison E, Sahyoun M, et al.

    Cornea 2020; (39(6)):680-684 doi:10.1097/ICO.0000000000002281.

    PMID: 32118671
  13. 13

    Evaluation of safety and efficacy of cyclosporine-A eye drops in herpetic stromal keratitis: a prospective randomized clinical trial.

    Lotfy NM, Alshatti H, Khachaba RY, Hagras SM

    Journal of ophthalmic inflammation and infection 2026; (16(1)).

    PMID: 41784713
  14. 14

    Pathogenesis of Herpes Stromal Keratitis: Immune Inflammatory Response Mediated by Inflammatory Regulators.

    Wang L, Wang R, Xu C, Zhou H

    Frontiers in immunology 2020; (11()):766 doi:10.3389/fimmu.2020.00766.

    PMID: 32477330
  15. 15

    Long-Term Outcomes of Deep Anterior Lamellar Keratoplasty Treating Posterior Stroma-Implicated Herpetic Corneal Opacities.

    Ren Y, Wang H, Zheng Q, et al.

    Cornea 2016; (35(3)):299-304 doi:10.1097/ICO.0000000000000742.

    PMID: 26785303
  16. 16

    Corneal Graft Success Rates in HSV Keratitis: A Systematic Review.

    Skarentzos K, Chatzimichael E, Panagiotopoulou EK, et al.

    Acta medica (Hradec Kralove) 2020; (63(4)):150-158 doi:10.14712/18059694.2020.57.

    PMID: 33355075
  17. 17

    Ocular surgery after herpes simplex and herpes zoster keratitis.

    Kanclerz P, Alio JL

    International ophthalmology 2020; (40(12)):3599-3612 doi:10.1007/s10792-020-01539-6.

    PMID: 32910331
  18. 18

    Clinical manifestations and outcomes of HSK following corneal transplantation.

    Wu D, Huang H, Zheng M, et al.

    Frontiers in medicine 2025; (12()):1654643 doi:10.3389/fmed.2025.1654643.

    PMID: 40909445

This page provides educational information about managing HSV stromal keratitis long-term. Always consult your ophthalmologist regarding your specific medications, surgical options, or eye pressure management.

Get notified when new evidence is published on Herpes simplex virus stromal keratitis.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.