What is the recommended treatment for herpes ophthalmicus?

Treatment of Herpes Ophthalmicus

For herpes ophthalmicus, oral valacyclovir 1000 mg three times daily for 7 days is the recommended first-line treatment due to its superior bioavailability and simpler dosing schedule compared to other antivirals. 1

Treatment Algorithm for Herpes Ophthalmicus

Initial Treatment

• First-line therapy:

  • Valacyclovir 1000 mg orally three times daily for 7 days 1
  • Alternative: Valacyclovir 500 mg orally 2-3 times daily for 7 days 1

• Alternative oral options:

  • Acyclovir 800 mg orally 5 times daily for 7 days 2
  • Famciclovir 500 mg orally three times daily for 7 days 1

• Topical options (as adjunctive therapy):

  • Ganciclovir 0.15% gel 3-5 times daily 2, 1
  • Trifluridine 1% solution 5-8 times daily (limit use to <2 weeks due to epithelial toxicity) 2, 1

For Severe Disease Requiring Hospitalization

• Acyclovir 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution 2, 1
• For immunocompromised patients: consider higher doses or longer duration 1

Important Clinical Considerations

Critical Warnings

• Do not use topical corticosteroids in active epithelial HSV infections as they potentiate viral replication 2, 1
• Do not rely solely on oral antivirals for HSV blepharoconjunctivitis - addition of topical antiviral treatment is more effective 1
• Do not use topical trifluridine beyond 2 weeks due to inevitable epithelial toxicity 2, 1

Special Populations

• Immunocompromised patients:

  • May require more aggressive treatment with higher doses or longer duration 1
  • Consider IV acyclovir 10 mg/kg every 8 hours in severe cases 1

• Patients with renal impairment:

  • Require dose adjustment of antiviral medications 1

Treatment of Persistent or Recalcitrant Disease

• Increase valacyclovir to 1000 mg every 8 hours for 7 days 1
• Consider adding topical antivirals if using oral therapy alone 1
• For chronic disease, prolonged treatment with dose adjustment based on clinical response may be necessary 1

Follow-up Recommendations

• Follow-up examination within 1 week of treatment initiation 2, 1
• Assessment should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy
  • IOP measurement

Long-term Management

• Lower doses of oral antivirals may be considered for prophylaxis against recurrent disease 2, 1
• Regular monitoring for complications such as:
  • Dry eye
  • Corneal anesthesia with neurotrophic keratitis
  • Post-herpetic neuralgia 1

Evidence Strength

Research demonstrates that prompt treatment with oral antivirals reduces the severity of skin eruption, ocular complications, and post-herpetic neuralgia 3. Studies comparing valacyclovir with acyclovir show similar efficacy in preventing ocular complications, but valacyclovir offers a simpler dosing schedule with better bioavailability (3-5 times higher than acyclovir) 1, 4.

Early treatment (within 72 hours of rash onset) is most effective in preventing ocular involvement and limiting visual morbidity 5, 6.