What is the treatment for herpes zoster ophthalmicus without rash?

Treatment for Herpes Zoster Ophthalmicus Without Rash

Valacyclovir 1000 mg three times daily for 7 days is the preferred treatment for herpes zoster ophthalmicus without rash due to its superior bioavailability and simpler dosing schedule compared to other antivirals. 1

First-Line Antiviral Therapy

• Valacyclovir 1000 mg three times daily for 7 days is the recommended first-line treatment for herpes zoster ophthalmicus (HZO), even in the absence of visible rash 1
• Alternative options include:
  • Acyclovir 800 mg five times daily for 7 days 1, 2
  • Famciclovir 500 mg three times daily for 7 days 1, 3
• Treatment should ideally be initiated within 72 hours of symptom onset for maximum efficacy in preventing ocular complications 4, 3

Management Approach

• Prompt ophthalmology consultation is essential for all suspected cases of HZO, even without visible rash, to prevent potential vision loss 1, 4
• Patients should be evaluated for ocular complications including:
  • Conjunctivitis (occurs in ~50% of cases) 3
  • Keratitis (both superficial and stromal) 5, 3
  • Uveitis 5, 3
  • Ocular cranial nerve palsies 4
• Monitor for dry eye and corneal anesthesia with neurotrophic keratitis, which can occur even without visible skin lesions 1

Adjunctive Therapy

• Topical antivirals alone have not been shown to be helpful in treating VZV conjunctivitis but may be used as additive treatment in unresponsive patients 5, 1
• Topical antibiotics may be prescribed to prevent secondary bacterial infection if any ocular surface compromise is present 5, 1
• Topical corticosteroids should be avoided in acute epithelial disease but may be considered under ophthalmology supervision for inflammatory complications 5

Special Populations

• Immunocompromised patients require more aggressive treatment and closer monitoring 5, 1
• For immunocompromised patients with severe infection, consider:
  • Intravenous acyclovir for complicated cases 5
  • Discontinuation of immunosuppressive therapy in severe cases 5
  • Longer duration of antiviral therapy based on clinical response 1

Follow-Up Care

• Schedule follow-up visit within 1 week of treatment initiation 5, 1
• Follow-up evaluation should include:
  • Interval history
  • Visual acuity measurement
  • Slit-lamp biomicroscopy
  • Assessment for development of complications 1
• Long-term monitoring is necessary as ocular complications can develop or recur weeks to months after initial presentation 5, 6
• Approximately 25-30% of patients may experience post-herpetic neuralgia after one month, requiring additional pain management 3

Prevention

• Consider zoster vaccination for at-risk individuals, particularly those who are older or immunocompromised 6
• The recombinant adjuvanted vaccine (RZV) is more effective than the live-attenuated vaccine (ZVL) in preventing HZO 6