When You Can't Find Trifluridine, You Still Have Options

A herpes simplex eye infection is not something you can put on hold. If your doctor prescribed Trifluridine (Viroptic) and you're having trouble finding it at your pharmacy, you're probably feeling anxious — and understandably so. Untreated herpetic keratitis can damage your cornea and threaten your vision.

The good news is that Trifluridine isn't your only option. Several alternative medications can treat herpes simplex eye infections effectively. Here's what you need to know about each one.

What Is Trifluridine and How Does It Work?

Trifluridine is an antiviral eye drop (1% ophthalmic solution) that belongs to a class of drugs called nucleoside analogues. It works by mimicking a building block of DNA. When the herpes simplex virus tries to replicate, it incorporates Trifluridine into its DNA instead of the real building block. This causes the viral DNA to malfunction, stopping the virus from multiplying.

Trifluridine has been FDA-approved since 1980 for treating primary keratoconjunctivitis and recurrent epithelial keratitis caused by herpes simplex virus types 1 and 2. It's applied as one drop every two hours while awake (up to nine drops per day) until the corneal ulcer heals.

While effective, Trifluridine has become increasingly difficult to find due to limited manufacturers and supply chain issues. If you can't fill your prescription, here are the alternatives your doctor may consider.

Alternative 1: Ganciclovir Ophthalmic Gel 0.15% (Zirgan)

Ganciclovir gel is the most common alternative to Trifluridine for herpetic keratitis. Like Trifluridine, it's a nucleoside analogue that interferes with viral DNA replication.

• FDA-approved for: Acute herpetic keratitis (dendritic ulcers)
• How to use: One drop in the affected eye five times daily until the ulcer heals, then three times daily for seven days
• Advantages: Fewer daily applications than Trifluridine (five vs. nine), may be better tolerated, and is often easier to find in stock
• Disadvantages: Can be expensive without insurance — the cash price can range from $500 to $700 for a 5-gram tube
• Common side effects: Blurred vision, eye irritation, punctate keratitis

Zirgan has become a preferred first-line treatment in many ophthalmology practices, so your doctor may already be familiar with switching patients to it.

Alternative 2: Oral Acyclovir or Valacyclovir

While Trifluridine and Ganciclovir gel are applied directly to the eye, oral antiviral medications can also be effective for herpes simplex eye infections, especially for stromal keratitis or as adjunctive therapy.

• Acyclovir (Zovirax): 400 mg taken five times daily, or 800 mg three times daily
• Valacyclovir (Valtrex): 500 mg to 1,000 mg taken two to three times daily
• Advantages: Widely available, much less expensive (generic Acyclovir can cost as little as $10–$30), and also helps prevent recurrences when used long-term at lower doses
• Disadvantages: May not be as effective as topical treatment alone for epithelial keratitis; works best when combined with a topical antiviral
• Common side effects: Nausea, headache, diarrhea

Many ophthalmologists use oral antivirals in combination with topical treatment. If you can't find Trifluridine, your doctor might prescribe oral Valacyclovir along with Ganciclovir gel, or sometimes oral antivirals alone if topical options are unavailable.

Alternative 3: Acyclovir Ophthalmic Ointment

Acyclovir ophthalmic ointment (3%) is widely used outside the United States for herpetic keratitis. While it's not FDA-approved as an ophthalmic product in the U.S., it is available in many other countries and some U.S. ophthalmologists may be able to access it through specialty channels.

• How to use: A small ribbon of ointment applied inside the lower eyelid five times daily
• Advantages: Well-studied, effective, and inexpensive in countries where it's available
• Disadvantages: Not readily available in the U.S.; ointment can cause temporary blurred vision

How to Decide Which Alternative Is Right for You

The best alternative depends on your specific situation. Here are some factors your ophthalmologist will consider:

• Type of infection: Epithelial keratitis responds well to topical antivirals (Ganciclovir gel or Trifluridine). Stromal keratitis may require oral antivirals plus topical steroids.
• Severity: More severe infections may benefit from combination therapy (topical plus oral antivirals).
• Cost: If cost is a concern, generic oral Acyclovir is the most affordable option. Ganciclovir gel is more expensive but may be partially covered by insurance.
• Availability: Use Medfinder to check which medications are currently in stock near you.

Never switch medications on your own. Always talk to your ophthalmologist before making any changes to your treatment plan.

Final Thoughts

Not being able to find Trifluridine is stressful, but it doesn't mean you're out of options. Ganciclovir gel (Zirgan) is the closest alternative and works in a similar way. Oral antivirals like Acyclovir and Valacyclovir are widely available and affordable. Your ophthalmologist can help you choose the best option for your situation.

To check real-time availability of Trifluridine and its alternatives, visit Medfinder. For more information, see our related guides:

• How to find Trifluridine in stock near you
• What is Trifluridine?
• How to save money on Trifluridine