What is the treatment for Herpes zoster ophthalmicus?

Treatment for Herpes Zoster Ophthalmicus

Prompt systemic antiviral therapy is the cornerstone of treatment for herpes zoster ophthalmicus and should be initiated within 72 hours of rash onset to prevent ocular complications. 1

Diagnosis and Initial Assessment

• Herpes zoster ophthalmicus (HZO) occurs when the varicella-zoster virus reactivates in the ophthalmic division of the trigeminal nerve
• Key clinical features:
  • Periorbital vesicular rash distributed along the ophthalmic dermatome
  • Potential involvement of the eye including conjunctivitis, keratitis, uveitis, and ocular cranial nerve palsies
  • Hutchinson's sign (vesicles on the tip of the nose) indicates higher risk of ocular involvement

Treatment Algorithm

1. Systemic Antiviral Therapy

• First-line treatment (start within 72 hours of rash onset):
  • Acyclovir: 800 mg five times daily for 7 days 2
  • Valacyclovir: 1000 mg every 8 hours for 7 days 2
  • Famciclovir: 500 mg three times daily for 7 days 2
• For immunocompromised patients: Consider higher doses or intravenous therapy
• For chronic/recalcitrant disease: May require prolonged treatment with dose adjustment based on clinical response 2

2. Ocular Management Based on Specific Manifestations

For Conjunctivitis

• Supportive care with artificial tears
• Monitor for secondary bacterial infection
• Topical antibiotics only if secondary bacterial infection is suspected

For Keratitis

• Epithelial (pseudodendritic) keratitis:

  • Self-limited and may not require specific antiviral therapy 3
  • Consider topical antivirals (ganciclovir 0.15% gel or trifluridine 1%) as adjunctive therapy 2

• Stromal keratitis:

  • Topical corticosteroids with concurrent oral antiviral coverage 3
  • Caution: Monitor for steroid-related complications (glaucoma, cataract)

For Uveitis

• Topical cycloplegics (e.g., atropine) to prevent synechiae
• Topical steroids under ophthalmologic supervision
• Continue oral antiviral coverage

For Neurotrophic Keratopathy

• Aggressive lubrication with preservative-free artificial tears
• Consider punctal occlusion
• For severe cases: Tarsorrhaphy or conjunctival flap may be necessary 3

3. Pain Management

• Acute phase: NSAIDs, acetaminophen, or short-term opioids if necessary
• For postherpetic neuralgia:
  • Gabapentin or pregabalin
  • Tricyclic antidepressants
  • Topical lidocaine patches

Follow-up and Monitoring

• Initial follow-up within 1 week of treatment initiation 2
• Regular monitoring for:
  • Treatment response
  • Development of ocular complications
  • Intraocular pressure if on topical steroids
  • Corneal sensation and integrity

Prevention Strategies

• Vaccination is strongly recommended:
  • Recombinant zoster vaccine (RZV, Shingrix) is preferred over zoster vaccine live (ZVL, Zostavax) 4
  • Recommended for adults aged 50 years and older 2, 4
  • Also recommended for adults aged 18 years and older who are immunocompromised 4
  • Administered as a 2-dose series 4

Important Considerations and Pitfalls

• Urgent ophthalmology consultation is necessary for any patient with suspected ocular involvement 5
• Avoid topical steroids without antiviral coverage as this may potentiate viral replication
• Neurotrophic keratopathy can develop even after resolution of acute infection, requiring long-term monitoring
• Up to 25% of patients with ocular involvement may develop chronic or recurrent disease 5
• Patients with HZO should avoid contact with high-risk individuals (pregnant women without history of chickenpox, immunocompromised individuals, infants) until lesions have crusted 4

Patient Education

• Importance of completing the full course of antiviral therapy
• Need for regular follow-up, especially with ocular involvement
• Proper hygiene measures to prevent transmission
• Recognition of warning signs requiring immediate attention (increased pain, vision changes, new ocular symptoms)

By following this treatment approach, the risk of permanent sequelae including chronic ocular inflammation, vision loss, and debilitating pain can be significantly reduced.