What is the treatment for shingle (herpes zoster) conjunctivitis?

Treatment of Herpes Zoster Conjunctivitis

The treatment of herpes zoster conjunctivitis requires oral antiviral therapy with valacyclovir 1000 mg three times daily for 7 days as the first-line treatment, along with topical antibiotics to prevent secondary bacterial infection of conjunctival vesicles. 1, 2

Systemic Antiviral Therapy

• Valacyclovir 1000 mg three times daily for 7 days is the preferred treatment due to its superior bioavailability and simpler dosing schedule compared to acyclovir 1, 3
• Alternative oral antiviral options include:
  • Acyclovir 800 mg five times daily for 7 days 2
  • Famciclovir 500 mg three times daily for 7 days 2
• Treatment should be initiated at the earliest sign or symptom of herpes zoster for maximum effectiveness, ideally within 72 hours of rash onset 3, 4
• For immunocompromised patients, more aggressive treatment may be necessary with potential dose adjustments and longer duration 2, 1

Topical Therapy

• Topical antibiotics are recommended to prevent secondary bacterial infection of conjunctival vesicles, which can lead to severe scarring and cicatricial ectropion 2
• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis but may be considered as adjunctive therapy in unresponsive cases 2
• Avoid topical corticosteroids during the acute phase as they may potentiate viral infection 2

Management of Complications

• Monitor for ocular complications including:
  • Pseudodendrites and epithelial keratitis 2, 5
  • Stromal keratitis and corneal scarring 2, 5
  • Corneal vascularization and uveitis 2
  • Sectoral iris atrophy and secondary glaucoma 2
• For late mucous adherent keratopathy and stromal keratitis, topical corticosteroids may be considered but only after adequate antiviral coverage is established 5
• For exposure or neurotrophic keratopathy, use topical lubricants; severe cases may require tarsorrhaphy or conjunctival flap 5

Follow-up Care

• Schedule a follow-up visit within 1 week of treatment initiation 2, 1
• The follow-up examination should include:
  • Interval history and symptom assessment 2
  • Visual acuity measurement 2
  • Slit-lamp biomicroscopy to assess resolution and complications 2
• Monitor for late sequelae including dry eye and corneal anesthesia with neurotrophic keratitis 2
• Patients with chronic disease may require prolonged treatment with dose adjustment according to clinical response 2

Clinical Evidence Supporting Treatment

• Studies have shown that valacyclovir accelerates the resolution of herpes zoster-associated pain compared to acyclovir while maintaining a similar safety profile 6, 7
• The efficacy of valacyclovir has been confirmed in herpes zoster ophthalmicus with similar control of cutaneous lesions and ocular complications compared to acyclovir 6
• Early treatment with systemic antivirals significantly reduces the incidence of ocular complications including keratitis 4, 8

Common Pitfalls and Caveats

• Delaying antiviral therapy beyond 72 hours after rash onset may reduce treatment efficacy, though some benefit may still be observed 6
• Topical antivirals alone are insufficient for treating VZV conjunctivitis 2
• Dose adjustment is necessary for patients with renal impairment 3
• Referral to an ophthalmologist is strongly recommended when ocular involvement is present to limit visual morbidity 1, 4