What are the current recommendations for treating herpes ophthalmicus?

From the Guidelines

The current recommendations for treating herpes ophthalmicus include prompt initiation of oral antiviral therapy, typically with acyclovir (200 to 400 mg five times a day), valacyclovir (500 mg two or three times a day), or famciclovir (250 mg twice a day), as well as topical antiviral treatment with ganciclovir 0.15% gel or trifluridine 1% solution. Treatment should begin as soon as possible after diagnosis to reduce the risk of complications and improve outcomes 1.

Key Considerations

• Oral antivirals alone may not be adequate in preventing the progression of HSV blepharoconjunctivitis, but the addition of topical antiviral treatment has been effective 1.
• Topical trifluridine inevitably causes epithelial toxicity if used for more than 2 weeks, while topical ganciclovir is less toxic to the ocular surface 1.
• Topical corticosteroids potentiate HSV infection and should be avoided 1.
• Patients should have a follow-up visit within 1 week of treatment to assess the response to therapy and detect any potential complications 1.

Management

• Preservative-free artificial tears can help with ocular discomfort.
• Pain management typically includes acetaminophen or NSAIDs, with stronger analgesics reserved for severe cases.
• Patients should be advised to avoid touching the rash, maintain good hand hygiene, and keep the affected area clean to prevent secondary bacterial infection.
• Cool compresses may provide symptomatic relief.
• Ophthalmology consultation is essential for all cases with eye involvement to assess for complications like keratitis, uveitis, or increased intraocular pressure.

Special Considerations

• Immunocompromised patients may require longer treatment courses and closer monitoring.
• Neonates require prompt consultation with the pediatrician or primary care physician, because systemic HSV infection is a life-threatening condition 1.

From the Research

Current Recommendations for Herpes Ophthalmicus

The current recommendations for treating herpes ophthalmicus are based on several studies that have investigated the efficacy of antiviral medications in reducing the severity and incidence of ocular complications and postherpetic pain.

• Antiviral Medications: The use of antiviral medications such as acyclovir and valacyclovir is generally recommended as the standard first-line treatment for herpes zoster ophthalmicus infections 2.
• Duration of Treatment: A study published in 1992 found that a 7-day course of oral acyclovir was sufficient in reducing the severity of skin eruption, ocular complications, and postherpetic neuralgia 3.
• Comparison of Acyclovir and Valacyclovir: A review published in 2016 compared the effects of valacyclovir and acyclovir for the treatment of herpes zoster ophthalmicus in immunocompetent patients, but the results were uncertain due to methodological limitations and low certainty of evidence 2.
• Topical Antiviral Therapy: Topical antiviral therapy with 3% acyclovir ophthalmic ointment may be effective in treating herpetic anterior uveitis, especially in patients who have not received corticosteroids 4.
• Oral Acyclovir: Oral acyclovir has been shown to modify the disease process in herpes zoster ophthalmicus, reduce the severity and incidence of postherpetic pain, and protect against long-term ocular complications 5.
• Intravenous Acyclovir: Intravenous acyclovir may be considered for patients at risk for AIDS who develop herpes zoster ophthalmicus, as it may shorten the disease course and reduce complications 6.