What is the treatment for Zoster ophthalmicus?

Treatment for Herpes Zoster Ophthalmicus

For herpes zoster ophthalmicus, oral antiviral therapy should be initiated as soon as possible, with valacyclovir 1000 mg three times daily for 7 days being the preferred treatment due to its superior bioavailability and simpler dosing schedule compared to acyclovir. 1, 2

First-Line Therapy

Oral Antiviral Medications

• Valacyclovir: 1000 mg three times daily for 7 days 1, 2, 3

  • Preferred due to better bioavailability and simpler dosing schedule
  • As effective as acyclovir for controlling ocular complications 3
  • Significantly accelerates resolution of zoster-associated pain compared to acyclovir 2, 4

• Alternative options:

  • Acyclovir: 800 mg five times daily for 7 days 1, 5, 6
  • Famciclovir: 500 mg three times daily for 7 days 1, 2

Timing of Treatment

• Initiate treatment at the earliest sign or symptom of herpes zoster 7, 5
• Most effective when started within 48-72 hours of rash onset 6, 8
• Some benefit may still be achieved with treatment initiated after 72 hours 2

Adjunctive Therapy

Topical Treatment

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

Special Considerations

• Immunocompromised patients may need more aggressive treatment 1
• Patients with renal impairment require dose adjustment 7, 5
• For chronic disease: Prolonged treatment with adjustment of dose according to clinical response 1

Management of Complications

Ocular Complications

• Involvement of an experienced ophthalmologist is strongly recommended for management of varicella zoster virus ocular disease 1
• Monitor for complications including:
  • Pseudodendrites, keratitis, corneal scarring 1
  • Corneal vascularization, uveitis 1
  • Sectoral iris atrophy and secondary glaucoma 1

Late Sequelae

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

Follow-Up Care

• Schedule follow-up visit within 1 week of treatment initiation 1
• Follow-up should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy
  • Assessment for resolution of acute symptoms and development of complications 1

Common Pitfalls and Caveats

• Avoid delaying treatment: Early initiation of antiviral therapy (within 72 hours) is crucial for reducing ocular complications and post-herpetic neuralgia 6, 8
• Renal function: Monitor renal function in elderly patients or those with known renal impairment; dose adjustments may be necessary 7, 5
• Compliance: Valacyclovir's simpler dosing schedule (3 times daily vs. 5 times daily for acyclovir) may improve patient compliance 2, 3
• Duration: Extending treatment beyond 7 days has not shown significant additional benefit 6, 4