What is the treatment for corneal perforation due to Herpes Zoster Ophthalmicus (HZO)?

Treatment of Corneal Perforation in Herpes Zoster Ophthalmicus (HZO)

Corneal perforation in Herpes Zoster Ophthalmicus requires immediate surgical intervention with keratoplasty (corneal transplantation) combined with systemic antiviral therapy to preserve ocular integrity and vision.

Immediate Management

• Urgent ophthalmology consultation for surgical evaluation
• Systemic antiviral therapy must be initiated or continued:
  • Acyclovir 800 mg 5 times daily for 7-10 days 1
  • Alternative: Valacyclovir 1000 mg three times daily (better bioavailability)
  • Continue antivirals during perioperative period

Surgical Management Options

1. Penetrating keratoplasty (PK) - full-thickness corneal transplant

   • First-line for most perforations
   • Required for large or central perforations

2. Deep anterior lamellar keratoplasty (DALK)

   • Consider for perforations without endothelial involvement
   • Better long-term graft survival in some cases 2

3. Tectonic keratoplasty

   • Emergency procedure to restore globe integrity
   • Used for acute perforations with risk of endophthalmitis 2

4. Boston keratoprosthesis

   • Consider in cases with severe inflammation or high risk of graft failure
   • Particularly useful in neurotrophic keratopathy from HZO 3

Perioperative Management

• Broad-spectrum topical antibiotics (e.g., moxifloxacin or levofloxacin) to prevent bacterial superinfection 4
• Temporary tarsorrhaphy often performed concurrently with keratoplasty to promote healing 2
• Avoid topical corticosteroids in active epithelial viral infection as they may potentiate infection 5
• Topical corticosteroids may be used post-operatively under close supervision for stromal inflammation 6

Post-operative Care

• Continue systemic antivirals for at least 3 months post-operatively to prevent recurrence
• Intensive ocular lubrication with preservative-free artificial tears to manage neurotrophic component 6
• Regular follow-up within 1 week of surgery and frequently thereafter
• Monitor for complications:
  • Graft rejection (reported in 36% of cases) 2
  • Secondary glaucoma (reported in 29% of cases) 2
  • Neurotrophic keratopathy (57% of cases) 2
  • Recurrent viral infection

Long-term Outcomes and Prognosis

• Visual outcomes: 43% of patients achieve 20/40 or better vision, and 64% achieve 20/100 or better vision following keratoplasty for HZO 2
• Graft survival is improved with:
  • Longer quiescent period between active HZO and keratoplasty
  • Concurrent tarsorrhaphy
  • Aggressive management of dry eye and neurotrophic keratopathy

Special Considerations

• Neurotrophic component must be addressed with:

  • Aggressive lubrication
  • Possible permanent or temporary tarsorrhaphy
  • Correction of lid abnormalities 6

• Superinfection risk is high in HZO perforations:

  • Obtain cultures before initiating antimicrobial therapy
  • Consider both bacterial and fungal pathogens (especially Candida) 4

• Wait period before elective keratoplasty:

  • If perforation is not acute, consider delaying surgery until inflammation subsides
  • Longer quiescent periods between active HZO and keratoplasty improve outcomes 2

The management of corneal perforation in HZO is challenging due to poor healing, high risk of superinfection, and surgical failure. However, with appropriate surgical intervention and comprehensive medical management, vision can be preserved in many cases.