What is the prophylactic treatment for herpes zoster (shingles) ophthalmicus?

Prophylactic Treatment for Herpes Zoster Ophthalmicus

Vaccination with recombinant zoster vaccine (RZV, Shingrix) is the most effective prophylactic treatment for preventing herpes zoster ophthalmicus in adults aged 50 years and older or adults aged 18 years and older who are immunocompromised. 1, 2

Primary Prevention: Vaccination

Recommended Vaccine

• RZV (Shingrix) is strongly recommended as the preferred vaccine for prevention of herpes zoster and its complications, including ophthalmicus 1, 2
• RZV is administered as a 2-dose series 2
• RZV is significantly more effective than the older zoster vaccine live (ZVL, Zostavax) which was discontinued in 2020 2

Target Populations

1. General population:

   • All immunocompetent adults aged 50 years and older 1, 2

2. High-risk populations (aged 18 years and older):

   • Immunodeficient or immunosuppressed individuals 2
   • Patients with autoimmune inflammatory rheumatic diseases 1
   • Individuals with diabetes mellitus, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease 1, 2

Special Considerations

• Patients who previously received ZVL should still receive RZV for better protection 1, 2
• Caution is advised when vaccinating patients with a history of herpes zoster ophthalmicus, as there have been rare reports of reactivation of herpes zoster keratitis after vaccination with live attenuated vaccine 3

Post-Exposure Prophylaxis

For non-immune individuals exposed to varicella zoster virus:

• Varicella zoster immune globulin (VZIG) should be administered as soon as possible but within 96 hours after close contact with a patient who has chickenpox or shingles 1
• This is particularly important for immunocompromised individuals who are VZV-seronegative 1

Antiviral Prophylaxis

While routine antiviral prophylaxis against reactivation of herpes zoster is not generally recommended 1, it may be considered in specific situations:

• For patients with a history of recurrent herpes zoster infections, especially those affecting the eyes 1
• For immunocompromised patients at high risk of reactivation 2
• When prophylaxis is indicated, valacyclovir 1 gram daily is typically used for suppressive therapy 4

Transmission Prevention for Active Cases

For patients with active herpes zoster ophthalmicus:

• Cover lesions until all have crusted over 2
• Frequent handwashing with soap and water 2
• Avoid contact with high-risk individuals (pregnant women who haven't had chickenpox, immunocompromised individuals, and infants) 2
• Use separate towels and pillows 2
• Implement isolation precautions, especially in healthcare settings 2

Early Recognition and Management

Early recognition and prompt treatment are critical to prevent complications:

• Initiate antiviral therapy within 72 hours of rash onset 4, 5
• Valacyclovir 1 gram three times daily for 7 days is the recommended dosage for treatment of herpes zoster 4
• Urgent ophthalmological consultation is necessary for any ocular involvement 2, 5

Common Pitfalls to Avoid

1. Delayed vaccination: Many eligible patients remain unvaccinated due to lack of provider recommendation 6
2. Inadequate post-exposure prophylaxis: Failure to administer VZIG within the 96-hour window 1
3. Delayed treatment initiation: Antiviral therapy is most effective when started within 72 hours of rash onset 4, 5
4. Failure to recognize ocular involvement: Approximately 50% of patients with herpes zoster ophthalmicus develop ocular disease, which requires urgent ophthalmological evaluation 6
5. Inadequate follow-up: Up to 25% of patients with ocular involvement develop chronic or recurrent disease requiring ongoing management 6

By implementing these prophylactic measures, particularly vaccination with RZV, the incidence of herpes zoster ophthalmicus and its potentially vision-threatening complications can be significantly reduced.