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Purpose: Herpes simplex virus (HSV) or varicella zoster virus (VZV)-associated ocular inflammation is usually treated with systemic topical antivirals and possibly corticosteroids. Although the use of immunomodulatory therapy (IMT) for virus associated inflammation may seem counterintuitive, our study aims to illustrate that IMT can be a viable approach in chronic, persistent cases where antiviral therapy alone fails to achieve long-term remission.

Methods: We retrospectively reviewed medical records of 31 patients with HSV- or VZV- associated ocular inflammation treated with immunomodulatory therapy. Inclusion criteria were antiviral- and corticosteroid-dependent ocular inflammatory disease requiring escalation to IMT. Viral etiology was confirmed by conjunctival or scleral biopsy, anterior chamber tap when appropriate or by strongly suggestive clinical findings. All patients received concomitant antiviral therapy during IMT treatment.

Results: HSV-associated inflammation accounted for 74 % of cases, while 26 % were associated with herpes zoster ophthalmicus. At last follow-up disease quiescence was observed in 24 patients (77.4%),6 patients (19.4%) had ongoing active inflammation.1 patient (3.2%) was lost to follow-up. All 6 patients with ongoing inflammation had HSV-associated disease. Methotrexate was the most used immunomodulatory agent, frequently in combination with biologic therapies such as adalimumab. Additional agents included mycophenolate mofetil, cyclosporine, or corticotropin gel. The mean duration of IMT was 31 months.8 patients (26%) remained on topical corticosteroids.

Conclusion: IMT may represent an effective adjunctive treatment for select patients with chronic, antiviral- and corticosteroid-dependent herpes virus–associated ocular inflammation when used alongside continuous antiviral suppression. These findings support a role for IMT in managing persistent immune-mediated inflammation triggered by or associated with herpes viruses.