Article Date: 8/1/2013

therapeutic focus
therapeutic focus

A New Treatment Algorithm for EHK

Ganciclovir as a first-line treatment


Recently, some eyecare practitioners have started prescribing ganciclovir ophthalmic gel 0.15% (Zirgan, Bausch + Lomb) as a first-line treatment for epithelial herpetic keratitis (EHK).

The reason: Recent Bausch + Lomb research reveals a first-line treatment algorithm is successful in eliminating the corneal ulcer quickly, while being well-tolerated by patients.

This article describes the treatment algorithm and provides insights from optometrists who have prescribed Zirgan as a first-line treatment for EHK.

Treatment algorithm

Upon discovering an epithelial dendrite, one drop of Zirgan is recommended five times daily until the corneal ulcer heals, according to the algorithm. Then, the practitioner should conduct follow-up appointments three to 14 days later (or sooner at the clinician’s discretion) to determine the ulcer’s status.

“With anything significant, we’re going to see patients back on a daily basis until we see resolution before we change the dosage of the drug,” explains Derek Cunningham, O.D., F.A.A.O., of Dell Laser Consultants in Austin, Texas.

If the ulcer improves upon follow-up, the patient should continue using it five times daily, and follow-up with his/her practitioner until healed (the absence of fluorescein staining at the ulcer site), according to the algorithm. Post-healing, the patient should continue to use one drop of Zirgan b.i.d. for the next seven days.

“I tell patients that the first couple days are going to be a little rough due to the tearing and foreign body sensation that typically accompanies active herpetic disease,” says J. James Thimons, O.D., medical director of Ophthalmic Consultants of Connecticut, in Fairfield, Conn. “However, by the third or fourth day, there’s a significant reduction in the level of visible keratitis and patient symptoms.”

Patient outcome

Dr. Thimons says he began treating EHK patients with Zirgan as a first-line treatment more than a year ago and has found the drug to work well due to the comfort level for patients.

“It has a relatively nontoxic ocular surface profile, which I think is very important in patients who are already quite uncomfortable,” he says.

The ability to treat patients right away has helped contribute to a fast recovery for most patients, says Dr. Cunningham.

“This is a selective therapy, so it allows us to be very aggressive in treating early on, even when we’re not quite sure of the diagnosis, because there’s very little downside,” says Dr. Cunningham.

Practice benefits

Zirgan has made a positive impact on practices due to the level of patient compliance associated with the drug, resulting in time saved due to fewer visits to the practice to treat EHK, say those interviewed. Having access to an agent that achieves success in treatment without the side effects has led to a mutually beneficial outcome, says Dr. Thimons.

“The patient and practice benefit because of the sharp decrease in overall time spent in the office,” he says. “I think that’s a good thing for everybody.”

Dr. Cunningham adds that, before using Zirgan as a first-line treatment, EHK patients often would fill his practice’s call box with complaints of discomfort. “We don’t get [those calls] anymore,” he says. OM

Coverage of Zirgan also appeared in the July 2010 issue of OM (

Optometric Management, Volume: 48 , Issue: August 2013, page(s): 52