What is the treatment for herpes zoster (shingles) that has spread from the head to the eye?

Treatment for Herpes Zoster Ophthalmicus (Shingles in the Eye)

Immediate oral antiviral therapy with valacyclovir 1 gram three times daily for 7 days is the recommended treatment for herpes zoster that has spread from the head to the eye. 1, 2

Antiviral Medication Options

First-line Treatment:

• Valacyclovir: 1 gram 3 times daily for 7 days
  • Preferred due to better bioavailability and more convenient dosing schedule 1
  • Therapy should be initiated at the earliest sign of herpes zoster and is most effective when started within 48 hours of rash onset

Alternative Options:

• Acyclovir: 800 mg 5 times daily for 7 days 3, 4
• Famciclovir: 500 mg 3 times daily for 7 days 3

Treatment Algorithm for Herpes Zoster Ophthalmicus

1. Immediate ophthalmology consultation

   • Suspected ocular vaccinia infections should be managed with an ophthalmologist to ensure thorough evaluation including slit-lamp examination 2

2. Systemic antiviral therapy

   • Start within 72 hours of rash onset for maximum effectiveness 4
   • Continue until all lesions have scabbed 2

3. For uncomplicated cases:

   • Oral antiviral therapy as outlined above
   • Regular follow-up to monitor for ocular complications

4. For severe or disseminated cases:

   • Consider intravenous acyclovir 10 mg/kg every 8 hours 5
   • Temporary reduction in immunosuppressive medications if applicable 2

5. For immunocompromised patients:

   • More aggressive therapy may be needed
   • Longer treatment duration and closer monitoring 5

Management of Ocular Complications

• Keratitis: Topical antiviral agents (trifluridine) may be added to systemic therapy 6
• Uveitis: Consider adding topical corticosteroids under ophthalmologist supervision 6
• Conjunctivitis: Supportive care with lubricating eye drops

Pain Management

• Acute pain:

  • Acetaminophen or NSAIDs for mild pain
  • Gabapentin or tricyclic antidepressants for moderate to severe pain 5

• Post-herpetic neuralgia (if it develops):

  • Gabapentin (titrate to 2400 mg per day in divided doses)
  • Tricyclic antidepressants
  • Capsaicin (8% dermal patch) for peripheral neuropathic pain 5

Follow-up Care

• Re-examine patient 3-7 days after initiation of therapy 5
• Monitor for:
  • Treatment response
  • Complete resolution of lesions
  • Signs of dissemination or complications
  • Development of post-herpetic neuralgia

Important Considerations

• Timing is critical: Treatment efficacy decreases significantly if started >72 hours after rash onset 4
• Ocular involvement: Herpes zoster ophthalmicus has high morbidity related to eyelid scarring, ocular complications, and post-herpetic neuralgia if not treated promptly 4
• Prevention: Recombinant zoster vaccine (RZV) is recommended for adults 50 years and older to prevent herpes zoster and its complications 2

Patient Education

• Avoid close contact with susceptible individuals (immunocompromised persons, pregnant women without history of chickenpox, and newborns) until lesions have crusted 5
• Proper hand hygiene to prevent spread
• Importance of completing the full course of antiviral medication
• Return immediately if vision changes or eye pain worsens

Early and aggressive treatment with systemic antivirals significantly reduces the risk of serious ocular complications and post-herpetic neuralgia in patients with herpes zoster ophthalmicus 4.