Herpes stromal disease is due to direct damage as a result of viral replication, virally induced immune mechanisms, or a combination of the two. Viral replication may have a major initiating role in the production of herpes simplex and herpes zoster induced stromal disease, and steroids may initially be harmful in their treatment. On topical antiviral drugs alone, in patients who never previously had had topical steroids, 14 of 15 cases of herpes simplex induced disciform keratitis responded favourably in an average of 44 days of treatment. This compared with one out of 14 responding if steroids had previously been used, 13 of 14 requiring topical steroids and an average 112 days' treatment. In herpes zoster stromal disease cases 78% had epithelial involvement, 54 of 57 responded to topical antivirals alone without the use of steroids, 2% recurred, and treatment averaged a total of 62 days. If steroids were used alone or in combination with antivirals, there was a 50% recurrence rate and 200 day total treatment duration.
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