What is the treatment for herpes zoster ophthalmicus?

Treatment of Herpes Zoster Ophthalmicus

The standard treatment for herpes zoster ophthalmicus is oral antiviral therapy with valacyclovir 1000 mg three times daily for 7 days, which should be initiated within 72 hours of rash onset for optimal outcomes. 1, 2

First-Line Systemic Antiviral Therapy

Recommended Medications and Dosing

• Valacyclovir: 1000 mg orally three times daily for 7 days 2
  • Preferred due to better bioavailability and simpler dosing schedule 3, 4
• Alternatives:
  • Acyclovir: 800 mg orally five times daily for 7 days 5
  • Famciclovir: 500 mg orally three times daily for 7 days 6

Timing of Treatment

• Initiate treatment as soon as possible, ideally within 72 hours of rash onset
• Recent evidence suggests benefit may still exist when started after 72 hours 4

Ophthalmology Consultation

Involvement of an experienced ophthalmologist is strongly recommended for all cases of herpes zoster ophthalmicus 5

The ophthalmologist will:

• Assess for corneal involvement (epithelial defects, stromal keratitis)
• Evaluate for anterior uveitis
• Monitor for increased intraocular pressure
• Determine need for additional topical therapy

Additional Topical Therapy

Based on ophthalmologic findings, additional treatments may include:

1. For conjunctivitis: Supportive care with artificial tears
2. For keratitis:
   • Topical antivirals alone have not shown significant benefit in VZV conjunctivitis but may be used as adjunctive therapy in unresponsive cases 5
   • Ganciclovir 0.15% gel may be preferred over trifluridine due to less ocular surface toxicity 1
3. For uveitis:
   • Topical corticosteroids at minimum effective dose with careful monitoring
   • Must be used in conjunction with systemic antiviral therapy 5, 1
   • Caution: Topical steroids should be avoided in epithelial disease without concurrent antiviral coverage

Follow-Up Care

1. Initial follow-up: Within 1 week of treatment initiation 5, 1

   • Assess symptom improvement
   • Check for corneal involvement
   • Evaluate for uveitis

2. Ongoing monitoring:

   • Regular follow-ups for patients with corneal or intraocular involvement
   • Monitor for post-herpetic neuralgia
   • Assess need for pain management

Special Populations

Immunocompromised Patients

• May require more aggressive treatment and longer duration 5
• Consider IV acyclovir for severe cases or immunocompromised patients 5

Children with Herpes Zoster Ophthalmicus

• Acyclovir 20 mg/kg body weight (maximum 800 mg/dose) orally four times daily for 7-10 days 5
• Topical antibiotics may be used to prevent secondary infection of eyelid vesicles 5

Complications and Management

Post-Herpetic Neuralgia

• Valacyclovir has been shown to reduce the duration of post-herpetic neuralgia compared to acyclovir 3, 4
• Pain management may include:
  • Gabapentin or pregabalin
  • Tricyclic antidepressants
  • Topical lidocaine or capsaicin

Late Sequelae

• Monitor for dry eye and corneal anesthesia with neurotrophic keratitis 5
• Long-term prophylaxis may be considered for patients with frequent recurrences 1

Clinical Pearls and Pitfalls

• Do not delay treatment waiting for definitive diagnosis; clinical suspicion is sufficient to start therapy
• Do not use topical corticosteroids without concurrent systemic antiviral coverage
• Do not discontinue antiviral therapy prematurely, even if symptoms improve
• Valacyclovir offers better bioavailability and simpler dosing compared to acyclovir, with similar safety profiles 4, 7
• Patients with renal impairment require dose adjustment of antiviral medications 2