What is the treatment for Herpes zoster ophthalmicus?

Treatment for Herpes Zoster Ophthalmicus

The treatment of herpes zoster ophthalmicus requires prompt oral antiviral therapy with valacyclovir 1000 mg three times daily for 7 days as the first-line treatment due to its superior bioavailability compared to other antivirals. 1

First-Line Antiviral Therapy

• Valacyclovir 1000 mg three times daily for 7 days is the preferred treatment for herpes zoster ophthalmicus 1, 2
• Alternative options include:
  • Acyclovir 800 mg five times daily for 7 days 3
  • Famciclovir 500 mg three times daily for 7 days 3, 4
• Treatment should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash 2, 5

Management of Ocular Complications

• Topical antibiotics may be prescribed to prevent secondary bacterial infection of eyelid vesicles that undergo necrosis before healing 3
• Topical antivirals alone are not effective for VZV conjunctivitis but may be used as adjunctive treatment in unresponsive cases 3
• Monitor for complications including:
  • Pseudodendrites, keratitis, corneal scarring 3
  • Corneal vascularization, iritis/uveitis 3, 6
  • Sectoral iris atrophy and secondary glaucoma 3, 6
  • Late sequelae such as dry eye and corneal anesthesia with neurotrophic keratitis 3, 6

Special Considerations

• Immunocompromised patients may require more aggressive treatment with higher doses or longer duration of antiviral therapy 3
• Patients with chronic disease may need prolonged treatment with dose adjustment according to clinical response 3
• Caution is advised when using systemic antiviral therapy in patients with impaired renal clearance 3, 2
• Severe conjunctival scarring from secondary bacterial infection can lead to cicatricial ectropion 3

Prevention

• Recombinant zoster vaccine (RZV) is strongly recommended for:
  • Immunocompetent adults aged 50 years or older 3
  • Immunocompromised patients 19 years and older 3
• Vaccination significantly reduces the incidence of herpes zoster and associated complications including herpes zoster ophthalmicus 3

Follow-Up Care

• Schedule follow-up examination within 1 week of treatment initiation 3, 1
• Follow-up visits should include:
  • Interval history and visual acuity measurement 3, 1
  • Intraocular pressure measurement 3
  • Slit-lamp biomicroscopy to assess for resolution and complications 3, 1
• Long-term monitoring may be necessary for patients who develop chronic sequelae 3, 6

Common Pitfalls to Avoid

• Delaying antiviral treatment beyond 72 hours after rash onset significantly reduces efficacy in preventing ocular complications 5, 7
• Using topical corticosteroids without appropriate antiviral coverage can worsen infection 3, 6
• Failure to recognize and treat secondary bacterial infections of vesicles 3
• Inadequate follow-up, particularly in cases with ocular involvement, can lead to permanent vision loss 6, 8
• Underestimating the potential for severe complications in immunocompromised patients 3, 8

Prompt diagnosis and treatment of herpes zoster ophthalmicus are essential to prevent vision-threatening complications. Ophthalmology consultation is strongly recommended when there is ocular involvement to ensure appropriate management and follow-up care 1, 5.