Ocular antiviral therapy in perspective

Antiviral agents

Amantadine is well established as the preferred antiviral agent for the prophylaxis of influenza A and may also be beneficial therapeutically when used early in the course of the disease. Idoxuridine is applicable only in the treatment of herpetic keratitis. Currently, acyclovir is the most effective agent for the treatment of herpes simplex and varicella-zoster virus infections. Ribavirin has recently been released for use in aerosol form for severe respiratory syncytial virus infections that occur in infants and young children. Vidarabine, which previously was the drug of choice in the treatment of severe herpetic infections, has now been replaced by the more effective acyclovir. Ganciclovir, an experimental agent, has shown promise against cytomegalovirus infections in patients who have undergone kidney or liver transplantation, but its effects are only temporary in patients who have undergone bone marrow transplantation and patients with acquired immunodeficiency syndrome (AIDS) who have cytomegalovirus infections.

New antiviral compounds

Several potent and selective antiviral agents against herpes virus infections have been developed. However, the majority of compounds against other viral diseases has not yet reached such high standard. Based on progress in molecular virology it can, however, be anticipated that similar concepts of selective inhibition will also be developed for other virus groups. In addition to virus-induced enzymes, viral proteins other than enzymes with specific activities will be identified. The identification of active sites will lead to the design of new and specific inhibitors. Moreover, studies on the mode of action of the huge number of known antiviral compounds may provide the basis for new and potent approaches to specific virus chemotherapy. New inhibitors of viral replication may also be derived from 2'-5'A and other mediators of the interferon induced antiviral state. However, since 2'-5'A does not enter cells, is rapidly degraded by phosphodiesterases, and affects viral and cellular protein synthesis, only analogs which do not have these disadvantages may qualify as antiviral drugs. In addition to refinements at the molecular level quantitative assays for a better evaluation of antiviral agents for clinical use are required. For clinical trials, rapid diagnosis, early initiation of treatment, and quantitative evaluation of the antiviral effects of a drug need to be developed. Moreover, new methods of drug delivery and/or drug targeting will improve potency and selectivity of antiviral compounds. Drug carriers have already successfully been used in cancer therapy (Poste and Fidler, 1981) they should be also applicable to virus chemotherapy. Finally, a better understanding of the pathogenesis and the natural course of viral diseases will contribute to the development of more effective and safe antiviral agents.

Evaluation of prodrugs of 9-beta-D-arabinofuranosyladenine for therapeutic efficacy in the topical treatment of genital herpesvirus infections in guinea pigs

Prodrugs of the antiviral agent 9-beta-D-arabinofuranosyladenine (araA), which were more effective than the parent compound in penetrating vaginal membranes in vitro, were synthesized and examined for efficacy in the topical treatment of genital infections with herpes simplex virus type 2 in female guinea pigs. Treatment with 10% araA-5'-monophosphate or 10% araA-5'-monovalerate twice a day for 7 days, starting 6 h after intravaginal inoculation with virus, completely aborted the primary infection. When initiation of treatment was delayed until 24 h postinfection, araA-5'-monophosphate and araA-5'-monovalerate were no longer effective in reducing the mean lesion scores or mean vaginal virus titers. Treatment with 5% acyclovir, starting at 24 h postinfection, failed to prevent genital lesion development but significantly reduced the peak mean lesion score (approximately 50%). Topical therapy with 10% araA-2',3'-diacetate, initiated at 24 h postinfection, was as effective as, if not more effective than, acyclovir in reducing the severity of herpes genitalis in guinea pigs. Treatment with 10% araA-2',3'-dipropionate or 10% araA-2',3'-dibutyrate was without benefit. Among a series of 5'-monoesters of araA, araA-5'-monobutyrate appeared to be the most effective but was less active than araA-2',3'-diacetate. These data indicate that araA-2',3'-diacetate may be an effective antiviral agent for topical use against genital herpesvirus infections.

Trifluridine: a review of its antiviral activity and therapeutic use in the topical treatment of viral eye infections

Trifluridine (trifluorothymidine) is an antiviral agent for topical use in the eye, and is structurally related to idoxuridine. In vitro studies have shown that it effectively inhibits the replication of herpes simplex virus type 1, which causes primary keratoconjunctivitis and recurrent epithelial keratitis in man. In masked comparative studies, predominantly in patients with dendritic ulcers, trifluridine 1% solution was effective in over 90% of patients; in such studies it was comparable with vidarabine in treating dendritic ulcers, and was at least as effective as, and in some studies more effective than, idoxuridine. The drug was also effective in treating a small number of patients with geographic ulcers (sometimes associated with the usage of topical corticosteroids), and this could be an important advantage if confirmed in further well-designed studies. However, experience at present is too limited to reliably determine the usual response rate in this difficult therapeutic area. In open studies the drug proved to be particularly useful in treating ulcers previously unresponsive to idoxuridine or vidarabine, and in treating patients intolerant of idoxuridine, with a high success rate and minimal side effects being reported. The role of trifluridine in treating deep stromal disease, uveitis, or adenovirus kerato-conjunctivitis has not been established. The drug is well tolerated and cross-hypersensitivity and cross-toxicity between trifluridine, idoxuridine and vidarabine are rare. Thus, trifluridine is an effective alternative to the drugs available for treating herpetic keratitis, and seems especially useful in 'difficult' cases.

Intraocular penetration of topically applied [14C]fosfonet sodium in rabbits

The intraocular penetration of [14C]fosfonet was studied following topical application of 25 mg of an ointment containing 5% [14C]fosfonet sodium onto the intact and abraded eyes of New Zealand white rabbits. Radioactivity penetrated rapidly through the abraded cornea and entered the anterior chamber. The concentration of fosfonet in the aqueous humor peaked at 7.2 microgram/ml by 90 min. Assuming an aqueous humor volume of 300 microliter, this level would correspond to approximately 0.2% of the applied dose. The highest concentration of fosfonet found in the abraded cornea was 0.3 microgram/mg, or 0.4% of the applied dose. The half-lives for the elimination of fosfonet from the aqueous humor and cornea were about 2.5 and 2.7 hr, respectively. The fosfonet levels in the iris were extremely low throughout the 6-hr period. The penetration of [14C]fosfonet through the intact cornea was considerably less than that found in the abraded eye. The peak concentrations of fosfonet in the aqueous humor and cornea of the intact eye were 0.26 microgram/ml and 0.02 microgram/mg, respectively, and occurred within 10 min of application of ointment.

In vivo reactivation of herpes simplex virus in rabbit trigeminal ganglia: electrode model

The rabbit provides an excellent model for the study of ocular herpes because herpetic keratitis in the rabbit eye resembles human disease in its clinical features and in its propensity for spontaneous recurrence. This paper presents a method for the electrical induction of multiple episodes of in vivo reactivation of latent HSV-1 infection with peripheral shedding of virus. Physiological levels of current delivered via an electrode implanted over the trigeminal ganglion of latently infected animals has enabled us to modify and synchronize virus shedding in preocular tear film and to cause multiple episodes of reactivation in a single animal. For this reason, the model is well suited for antiviral efficacy testing and provides an excellent opportunity for investigation of virus-host cell interactions in latent and recurring herpetic disease.

Combined antiviral effect of DNA inhibitors on Herpes simplex virus multiplication

The inhibition of herpesvirus type 1 in cell cultures by seven inhibitors of DNA synthesis and by pactamycin was investigated by plaque inhibition in Vero cells with agarose overlay, and by yield reduction in one-step growth in HeLa cells. While the plaque inhibition method proved to be suitable to show inhibition by single substances, only the yield reduction procedure was reliable for investigating the interaction of two substances. Inhibition was evaluated by means of an inhibition quotient (number of PFU in uninhibited virus controls:number of PFU in test specimen); combined inhibition was related to results with single substances. Among the 28 substance pairs, 9 cases of indifference, 10 additive, and 9 synergistic interactions were found. Indifference was observed only with fluorodeoxyuridine and amethopterin as one of the partners, which by themselves inhibited herpesvirus multiplication incompletely.

Ocular herpes simplex infection. A clinical evaluation of virus isolation and studies on iodo-deoxyuridine resistance

Fifty-seven patients with ocular herpes simplex (HS) infection were studied for evaluation of existing methods for virus isolation and its application in diagnosis of HS infection. Virus was isolated in 90% of 34 cases with keratitis dendritica, when specimens were taken within eight days of onset of symptoms. The same isolation frequency was obtained in 10 cases of palpebral herpes with conjunctivitis. No isolation was possible in 11 cases of keratitis disciformis. Laboratory confirmation was obtained within four days in 70% of the positive cases. Ten strains of HS virus type 1 were examined for IDU resistance, 5 strains isolated prior to and 5 during IDU treatment. Nine of the strains had the same degree of sensitivity. One strain isolated during treatment was found to be highly resistant.