Does herpes zoster ophthalmicus require steroid treatment?

Management of Herpes Zoster Ophthalmicus

Herpes zoster ophthalmicus (HZO) with ocular involvement requires systemic antiviral therapy, and topical steroids should be added when there is significant ocular inflammation, particularly with corneal involvement or orbital inflammation. 1, 2

Antiviral Therapy - First Line Treatment

• Systemic antivirals are the cornerstone of treatment for HZO:

  • Acyclovir: 800 mg five times daily for 7 days
  • Valacyclovir: 1000 mg every 8 hours for 7 days
  • Famciclovir: 500 mg three times daily for 7 days 1

• Initiate antiviral therapy as soon as possible for optimal outcomes

• Patients with chronic or recalcitrant disease may require prolonged treatment with dose adjustment based on clinical response 1

Role of Steroids in HZO Management

When to Add Steroids:

• Topical steroids are indicated for:

  • Significant ocular inflammation
  • Corneal involvement (keratitis, stromal disease)
  • Uveitis/iritis
  • Orbital inflammation 3, 2

• Systemic steroids should be considered for:

  • Orbital apex syndrome
  • Acute orbital inflammation (myositis, perioptic neuritis)
  • Ophthalmoplegia 2, 4

Cautions with Steroid Use:

• Always use steroids in conjunction with adequate antiviral coverage
• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis 1
• Monitor intraocular pressure and pupillary dilation in patients on prolonged topical corticosteroids 1
• Taper steroids slowly once inflammation is controlled 1

Management Algorithm Based on Clinical Presentation

1. Mild HZO with conjunctival involvement only:

   • Systemic antivirals
   • Topical lubricants
   • Topical antibiotics to prevent secondary infection 1

2. HZO with corneal involvement:

   • Systemic antivirals
   • Topical steroids (with caution)
   • Ophthalmology follow-up within 1 week 1

3. HZO with orbital inflammation or ophthalmoplegia:

   • Systemic antivirals
   • Systemic steroids
   • Urgent ophthalmology referral 3, 2

Steroid Selection and Monitoring

• For topical use, consider corticosteroids with poor ocular penetration (fluorometholone, loteprednol) to minimize risk of elevated IOP and cataract formation 1
• For systemic steroids in orbital inflammation, extended steroid taper may aid recovery of ophthalmoplegia (HR 1.1, p=0.04) 4
• Regular follow-up should include:
  • Visual acuity measurement
  • Intraocular pressure monitoring
  • Slit-lamp biomicroscopy 1

Important Clinical Pearls

• Distinguish HZO from HSV ocular disease - topical steroids potentiate HSV epithelial infections and should be avoided in HSV, but may be beneficial in HZO 1
• Late sequelae of HZO include dry eye and corneal anesthesia with neurotrophic keratitis 1
• Severe conjunctival scarring from secondary bacterial infection can lead to cicatricial ectropion 1
• Immunocompromised patients may need more aggressive treatment 1

Follow-up Recommendations

• Patients with severe disease should be re-evaluated within 1 week
• Patients with orbital involvement require more frequent monitoring
• Long-term follow-up is necessary as chronic sequelae may develop even after resolution of acute disease 1

Remember that HZO can initially present with orbital inflammatory signs without the typical zoster rash, so maintain a high index of suspicion in patients with acute orbital inflammation 3.