What is the recommended treatment for Herpes zoster conjunctivitis?

Treatment of Herpes Zoster Conjunctivitis

For herpes zoster conjunctivitis, oral antiviral therapy is the primary recommended treatment, with valacyclovir 1000 mg three times daily for 7 days being the most effective option due to superior bioavailability and simplified dosing compared to acyclovir. 1, 2

First-Line Treatment

Oral Antiviral Therapy

• Valacyclovir: 1000 mg three times daily for 7 days

  • Preferred due to better bioavailability and less frequent dosing 2, 3
  • Shown to accelerate resolution of herpes zoster-associated pain compared to acyclovir 4

• Alternative oral antivirals:

  • Acyclovir: 800 mg five times daily for 7 days 1
  • Famciclovir: 500 mg three times daily for 7 days 1

Treatment Timing

• Initiate treatment within 72 hours of rash onset for maximum effectiveness 5
• Recent evidence suggests benefit may still exist when starting treatment later than 72 hours 2

Adjunctive Therapy

Topical Treatments

• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis 1
  • May be used as additive treatment in unresponsive patients
• Topical antibiotics may be used to prevent secondary bacterial infection of vesicles 1

Special Considerations

• For persistent or recalcitrant disease, consider extending treatment duration 1
• Immunocompromised patients may require more aggressive treatment 1
• Adjust dosing in patients with impaired renal clearance 1

Management of Complications

Ocular Complications

• Monitor for associated ocular complications:

  • Pseudodendrites
  • Keratitis (epithelial, stromal)
  • Corneal scarring
  • Corneal vascularization
  • Iritis/uveitis
  • Sectoral iris atrophy
  • Secondary glaucoma 1

• For stromal keratitis:

  • Topical corticosteroids may be beneficial but should be used in conjunction with oral antiviral therapy 1
  • Use corticosteroids with poor ocular penetration (fluorometholone) or site-specific corticosteroids (loteprednol) to minimize risk of elevated IOP or cataract formation 1

Long-term Management

• Patients with chronic sequelae may require prolonged treatment and/or long-term prophylaxis 1
• Monitor for late sequelae including dry eye and corneal anesthesia with neurotrophic keratitis 1

Follow-up Care

• Regular follow-up examinations should include:
  • Interval history
  • Visual acuity measurement
  • IOP measurement
  • Slit-lamp biomicroscopy 1

Clinical Pearls and Pitfalls

Important Considerations

• Herpes zoster ophthalmicus represents up to 25% of all herpes zoster cases 5
• Permanent sequelae may include chronic ocular inflammation, vision loss, and debilitating pain 5

Common Pitfalls

• Failure to initiate antiviral therapy promptly
• Inappropriate use of topical corticosteroids without concomitant oral antiviral therapy
• Inadequate follow-up for potential complications
• Overlooking the need for dose adjustment in patients with renal impairment

When to Refer

• Refer to an ophthalmologist when there is:
  • Visual loss
  • Moderate or severe pain
  • Corneal involvement
  • Conjunctival scarring
  • Lack of response to therapy after 3-4 days 6