What is the inpatient treatment for herpes zoster ophthalmicus?

Inpatient Treatment for Herpes Zoster Ophthalmicus

The preferred inpatient treatment for herpes zoster ophthalmicus is intravenous acyclovir at a dose of 10 mg/kg body weight three times daily for 10-14 days, followed by oral valacyclovir 1 g three times daily for 4-6 weeks. 1

Antiviral Therapy

First-Line Treatment

• IV Acyclovir: 10 mg/kg body weight every 8 hours for 10-14 days 1
  • For severe cases requiring hospitalization
  • Some experts base dosing on body surface area (500 mg/m²/dose IV every 8 hours) for children >1 year 1
  • Alternative dosing: 5-10 mg/kg body weight IV every 8 hours for 5-7 days or until clinical resolution 1

Transition to Oral Therapy

After IV treatment course, transition to:

• Valacyclovir: 1 g three times daily for 4-6 weeks (for patients able to receive adult dosing) 1
• Alternative: Oral acyclovir 20 mg/kg body weight for 4-6 weeks 1

For Patients Not Responding to Acyclovir

• Foscarnet: 40-60 mg/kg body weight IV per dose three times daily for 7-10 days 1

Ophthalmologic Management

• Mandatory ophthalmology consultation: Involvement of an experienced ophthalmologist is strongly recommended for management of varicella zoster virus eye infections 1
• Regular follow-up: Should include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1

Special Considerations

Complications Management

• Corneal involvement: Monitor for pseudodendrites, keratitis, corneal scarring, and vascularization 1
• Intraocular complications: Watch for iritis/uveitis, sectoral iris atrophy, and secondary glaucoma 1
• Late sequelae: Monitor for dry eye and corneal anesthesia with neurotrophic keratitis 1

Dosing Considerations

• Renal impairment: Dose adjustment required for patients with impaired renal clearance 1
• Immunocompromised patients: May require more aggressive treatment with higher doses or longer duration 1

Alternative Oral Regimens (if IV therapy not feasible)

For less severe cases or when IV therapy is not possible:

• Valacyclovir: 1000 mg every 8 hours for 7 days 1, 2
  • Advantage: Simpler dosing schedule (three times daily) with similar efficacy to acyclovir 2
• Acyclovir: 800 mg five times daily for 7-10 days 1, 3, 4
• Famciclovir: 500 mg three times daily for 7 days 1

Important Clinical Pearls

• Early treatment is crucial: Starting antiviral therapy within 72 hours of rash onset significantly reduces the risk of severe ocular complications 3, 5
• Avoid topical corticosteroids in acute phase as they may potentiate viral infection 1
• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis but may be used as additive treatment in unresponsive patients 1
• Chronic disease may require prolonged treatment with dose adjustment according to clinical response 1
• Oral valacyclovir may be an effective alternative to IV acyclovir in selected immunocompetent patients with HZO-induced optic neuritis 6

Remember that prompt initiation of appropriate antiviral therapy is essential to reduce morbidity, prevent vision loss, and minimize the risk of post-herpetic neuralgia.