Raging epidemic keratoconjunctivitis (EKC) can be spotted from across the room. For years, we had to rely on palliative therapy due to the virus’ lack of susceptibility to treatment. Cost, availability, and insurance coverage are significant obstacles to using topical antivirals. Topical steroids can improve comfort, reduce subepithelial infiltrates (SEIs), and prevent scarring; however, they also enhance adenovirus replication, which prolongs viral shedding.

In the last decade, the off-label use of 5% povidone-iodine lavage (PIL) for in-office treatment has become a popular mainstay therapy to reduce the viral load and to shorten clinical recovery time. Unfortunately, it often generates significant tissue disruption and discomfort, even with proper irrigation and use of topical anti-inflammatories and anesthetics.

Hypochlorous acid (HA) has powerful antiseptic and anti-inflammatory properties and a non-toxic safety profile. How does it work as an off-label treatment for EKC?

A Case in Point

A 24-year-old compliant contact lens wearer presented with intense photophobia, redness, and discomfort in both eyes for 48 hours. He reported symptoms of an upper respiratory tract infection, including a productive cough and nasal congestion; he denied fever, chills, shortness of breath, confusion, myalgias, ageusia, and anosmia. Asymmetric, 4+ diffuse conjunctival injection, chemosis, lid edema, and petechial hemorrhages OS>OD were observed along with serous discharge, follicular reaction, preauricular lymphadenopathy, and trace SEIs OS (Figure 1). Due to the coronavirus pandemic, the examination was conducted with appropriate personal protective equipment followed by thorough room sterilization.

Figure 1. Acute EKC with significant bilateral injection and follicular reaction.

We diagnosed presumed EKC and conducted a hypochlorous acid lavage (HAL) by placing two-to-three drops of 0.01% HA solution in each eye, following topical anesthesia and nonsteroidal anti-inflammatory drugs. The patient closed and rolled his eyes to help the HA coat the entire ocular surface while his lids were sprayed and cleaned with the same solution. His eyes were rinsed with saline, and a drop of topical steroid was instilled.

The patient tolerated the procedure well and was prescribed loteprednol etabonate 0.5% gel q.i.d. for five days, HA spray to the lids and periocular area b.i.d., and preservative-free artificial tears q2hrs. We advised him to discontinue lens wear, to self-quarantine, and to undergo COVID-19 testing (results were ultimately negative). At his two-day follow-up, the patient reported only mild itching and demonstrated near complete resolution of clinical signs. The steroid was tapered over the next few days, and he was released from follow-up care.

Study Is Warranted

Randomized, large-scale studies are needed to compare the efficacy and safety profiles between PIL and HAL; however, we have used HAL in dozens of EKC cases and have repeatedly witnessed similar resolution times, with less tissue disruption and improved tolerability. We believe that HAL may one day become a primary treatment option for EKC and other viral infections. CLS