Frequency and visual outcomes of herpes simplex keratitis in a Kuwaiti tertiary referral center

Background

Herpes simplex virus (HSV), a cause of many ocular pathologies, may affect the corneal epithelium, stroma, or endothelium, with the epithelium as the most frequently affected location. We aimed to determine the frequency and visual outcomes of HSV keratitis over a 1-year period at Farwaniya Hospital, Kuwait.

Methods

This prospective observational case series included patients diagnosed with HSV keratitis who presented to the outpatient or eye casualty department between September 2022 and September 2023. Full history, demographic profile, detailed ocular and slit-lamp examinations, and visual acuity assessments were recorded prior to and after treatment. Baseline corneal sensation was assessed in the four corneal quadrants using the cotton wisp test.

Results

Of the 227 patients who presented with infectious keratitis, 72 (31.7%) were diagnosed with HSV keratitis. The mean (SD) age was 45.86 (16.06) years, and 48 (66.7%) patients were male. The subtypes of HSV keratitis were endotheliitis in 27 (37.5%) patients, dendritic ulcer in 22 (30.6%), stromal keratitis with ulceration in 9 (12.5%) and without ulceration in 8 (11.1%), and geographic ulcer in 6 (8.3%). The mean baseline best-corrected distance visual acuity (BCDVA) differed significantly between the HSV keratitis subtypes (P < 0.001). Most patients (n = 70, 97.2%) had unilateral eye involvement, were treated within 1 - 2 weeks, and demonstrated improved BCDVA. Despite the improvement in BCDVA in all HSV keratitis subtypes, a significant difference in the median BCDVA remained after treatment (P < 0.001). Pairwise comparisons revealed a significantly better BCDVA after treatment in eyes with dendritic epithelial ulcers than in eyes with HSV stromal keratitis with ulceration (P = 0.003) or geographic epithelial ulcers (P = 0.005). After treatment, corneal haze and neovascularization were detected in 54 (75.0%) and 24 (33.3%) patients, respectively.

Conclusions

We detected a substantial frequency of HSV keratitis in one of the governorates of Kuwait, with endotheliitis as the most common manifestation. Timely standard treatment interventions based on valid guidelines resulted in BCDVA improvement in all subtypes of HSV keratitis in our series, indicating the importance of early treatment. However, the BCDVA in eyes with dendritic epithelial ulcers remained substantially better than that in eyes with geographic epithelial ulcers or HSV stromal keratitis with ulceration, signifying the effect of the initial HSV keratitis subtype on visual outcomes. To our knowledge, this is the first study to highlight the frequency of HSV keratitis in a Kuwaiti hospital, and larger-scale research in this region is needed to further understand and manage the condition.

Fabrication of Stimuli-Responsive Quince/Mucin Co-Poly (Methacrylate) Hydrogel Matrices for the Controlled Delivery of Acyclovir Sodium: Design, Characterization and Toxicity Evaluation

Free-radical polymerization technique was adopted to fabricate a stimuli-responsive intelligent quince/mucin co-poly (methacrylate) hydrogel for the controlled delivery of acyclovir sodium. The developed hydrogel matrices were appraised using different parameters, such as drug loading (%), swelling kinetics, pH- and electrolyte-responsive swelling, and sol-gel fraction. Drug-excipient compatibility study, scanning electron microscopy, thermal analysis, powder X-ray diffraction (PXRD) analysis, in vitro drug release studies, drug release kinetics and acute oral toxicity studies were conducted. The results of drug loading revealed an acyclovir sodium loading of 63-75% in different formulations. The hydrogel discs exhibited pH-responsive swelling behavior, showing maximum swelling in a phosphate buffer with a pH of 7.4, but negligible swelling was obvious in an acidic buffer with a pH of 1.2. The swelling kinetics of the developed hydrogel discs exhibited second-order kinetics. Moreover, the hydrogel discs responded to the concentration of electrolytes (CaCl₂ and NaCl). The results of the FTIR confirm the formation of the hydrogel via free-radical polymerization. However, the major peaks of acyclovir remain intact, proving drug-excipient compatibility. The results of the SEM analysis reveal the porous, rough surface of the hydrogel discs with multiple cracks and pores over the surface. The results of the PXRD disclose the amorphous nature of the fabricated hydrogel. The dissolution studies showed a minor amount of acyclovir sodium released in an acidic environment, while an extended release up to 36 h in the phosphate buffer was observed. The drug release followed Hixen-Crowell's kinetics with Fickian diffusion mechanism. The toxicity studies demonstrated the non-toxic nature of the polymeric carrier system. Therefore, these results signify the quince/mucin co-poly (methacrylate) hydrogel as a smart material with the potential to deliver acyclovir into the intestine for an extended period of time.

Long-term physicochemical stability of acyclovir 5 mg/mL solution stored in polypropylene bags as a simulated hospital stock preparation

PURPOSE

To investigate the long-term chemical and physical stability of 5-mg/mL acyclovir solution in polypropylene bags stored at 5°C ± 3°C for 2 months in order to determine the feasibility of batch production by a centralized intravenous additive service.

METHODS

Eight empty 100-mL polypropylene bags (bags A) and 8 empty 250-mL bags (bags B) were respectively filled with 60 mL and 200 mL of 5-mg/mL acyclovir and 0.9% sodium chloride injection (NaCl) under aseptic conditions through a semiautomated manufacturing process and vacuum packed before storage at 5°C ± 3°C. Four bags A and 4 bags B were tested for chemical stability via a stability-indicating high-performance liquid chromatography (HPLC) method immediately after preparation (time 0) and after 7, 14, 21, 28, 35, 42, and 63 days. Samples for microbiological assay were collected on days 0 and 63 from 4 bags A and 4 bags B immediately after breaking the vacuum. Osmolality, pH, and physical stability were assessed by visual examination, Subvisible particle counting was performed on 6 additional bags (3 each of bags A and B).

RESULTS

Mean percentage loss of acyclovir relative to the mean experimental concentration at time 0 was below 5% over the 63-day study period.. No significant differences of pH, no change in color and no precipitate were observed during the study. Subvisible particle counts were compliant with European Pharmacopoeia requirements. Acyclovir solutions remained sterile over the 63 days of the study.

CONCLUSION

Extemporaneously prepared acyclovir 5 mg/mL solutions in 0.9% NaCl stored in polypropylene bags were chemically and physically stable over 63 days when stored at 5°C ± 3°C.