What is the treatment for pediatric herpes ophthalmicus?

Treatment of Pediatric Herpes Ophthalmicus

Acyclovir is the drug of choice for treating pediatric herpes ophthalmicus, with specific dosing regimens based on the extent of ocular involvement and patient age. 1

Treatment Algorithm

For Herpes Simplex Virus (HSV) Ophthalmicus:

1. Initial Assessment:

   • Diagnose based on typical vesicular lesions and ulcers
   • Determine extent of ocular involvement (conjunctival only vs. corneal involvement)

2. Treatment Regimens:

   • Mild conjunctival involvement only:

     • Oral acyclovir 20 mg/kg/dose (maximum 400 mg/dose) three times daily for 7-10 days 1
     • Alternative: Topical ganciclovir 0.15% gel three to five times daily 1

   • Moderate to severe involvement or disseminated disease:

     • Intravenous acyclovir 5-10 mg/kg/dose three times daily 1
     • Switch to oral therapy once lesions begin to regress 1

   • CNS or disseminated disease:

     • Intravenous acyclovir 10 mg/kg/dose three times daily for 21 days 1
     • For neonatal CNS disease, continue until repeat CSF HSV DNA PCR is negative at days 19-21 1

3. Topical Therapy:

   • Avoid topical corticosteroids as they potentiate HSV infection 1
   • Consider topical ganciclovir 0.15% gel (less toxic than trifluridine) 1

For Herpes Zoster Ophthalmicus (HZO):

1. Systemic Therapy (start within 72 hours of rash onset for best outcomes) 2, 3:

   • Children ≥2 years: Oral acyclovir 800 mg five times daily for 7 days 2
   • Adolescents: Consider valacyclovir 1000 mg three times daily for 7 days 2

2. Topical Management:

   • Topical antibiotics to prevent secondary bacterial infection 1
   • Topical lubricants for comfort 2
   • Topical antivirals alone are not effective for VZV conjunctivitis 1

3. Adjunctive Therapy:

   • For significant inflammation: Consider topical corticosteroids with antiviral coverage 2
   • Use corticosteroids with poor ocular penetration (fluorometholone, loteprednol) to minimize IOP elevation 1

Follow-Up Protocol

• Initial Follow-up: Within 1 week of treatment initiation 1
• Assessment at Follow-up: Visual acuity, IOP measurement, slit-lamp biomicroscopy 1
• Long-term Monitoring: Regular follow-up to detect complications such as:
  • Corneal scarring (occurs in 79% of pediatric HSV keratitis cases) 4
  • Visual impairment (26% of children with HSV keratitis develop vision of 20/40 or worse) 4

Special Considerations

1. Recurrence Prevention:

   • For children with frequent HSV recurrences (>3-6 episodes/year): Consider suppressive oral acyclovir 1
   • Adjust dosage as child grows to prevent subtherapeutic levels 4

2. Neonatal HSV:

   • Requires immediate consultation with pediatrician as systemic HSV is life-threatening 1
   • High-dose IV acyclovir (20 mg/kg three times daily) for 14-21 days 1

3. Common Pitfalls:

   • Misdiagnosis is common (30% of pediatric HSV keratitis cases are initially misdiagnosed) 4
   • Failure to adjust acyclovir dosage during growth spurts can lead to treatment failure 4
   • Delayed treatment increases risk of corneal scarring and vision loss 4, 5

4. Monitoring for Side Effects:

   • Monitor for neutropenia with long-term acyclovir use (occurs in up to 46% of children) 1
   • Adjust dose in patients with renal insufficiency 1

Early diagnosis and prompt treatment are critical to reduce the risk of permanent visual impairment and other complications in pediatric herpes ophthalmicus. The high rate of recurrence (80% in HSV keratitis) underscores the importance of close follow-up and consideration of suppressive therapy in selected cases 4.