What is the treatment for ocular (herpes zoster ophthalmicus) shingles?

Treatment for Ocular Shingles (Herpes Zoster Ophthalmicus)

The treatment for ocular shingles requires prompt initiation of systemic antiviral therapy combined with aggressive ocular management, including daily ophthalmological review, ocular lubricants, and consideration of topical corticosteroids and antibiotics as needed. 1

Systemic Antiviral Therapy

• Initiate oral antiviral therapy within 72 hours of rash onset for maximum effectiveness 2, 3:

  • Valacyclovir: 1000 mg three times daily for 7 days 2
  • OR Famciclovir: 500 mg every 8 hours for 7 days 3

• Early antiviral therapy reduces viral shedding, promotes faster healing, and may decrease the risk of postherpetic neuralgia 4

• Treatment initiated beyond 72 hours after rash onset has not been established for efficacy but may still provide benefit in patients with active lesion formation 2, 3

Ocular Management

• Daily ophthalmological examination is essential during the acute illness to monitor for complications 1

• Apply non-preserved ocular lubricants (e.g., hyaluronate or carmellose eye drops) every 2 hours throughout the acute illness 1

• Perform daily ocular hygiene by an ophthalmologist or ophthalmically trained nurse to remove inflammatory debris and break down conjunctival adhesions 1

• For corneal epithelial defects or ulceration, administer broad-spectrum topical antibiotics (e.g., moxifloxacin or levofloxacin four times daily) 1

• Consider topical corticosteroid drops (e.g., non-preserved dexamethasone 0.1% twice daily) to reduce ocular surface inflammation and damage, but use with caution if corneal epithelial defects are present 1

• For unconscious patients, prevention of corneal exposure is essential using polyethylene film to create a moisture chamber 5

Management of Complications

• Nasociliary nerve involvement (indicated by lesions on the tip of the nose) is associated with higher risk of ocular complications and requires closer monitoring 6

• Common ocular complications include corneal hypesthesia, episcleritis, dendritiform keratopathy, stromal keratitis, and anterior uveitis, which typically present within the first two weeks 7

• For postherpetic neuralgia (occurring in up to 52% of patients), consider:

  • Tricyclic antidepressants (e.g., amitriptyline) in low doses 4, 8
  • Anticonvulsants (e.g., gabapentin, pregabalin) 4, 8
  • Topical treatments such as capsaicin or lidocaine patches for selected patients 4

Prevention

• Recommend the recombinant zoster vaccine (RZV) for prevention in:

  • Immunocompetent adults aged 50 years or older
  • Immunocompromised patients 19 years and older
  • Adults who previously received the older zoster vaccine live (ZVL) 1

• RZV is preferred over ZVL due to higher efficacy (96% vs. 70%) 1

Special Considerations

• Immunocompromised patients are at higher risk for disseminated disease and may require more aggressive treatment, possibly including intravenous antivirals 1

• Patients over 80 years of age are at higher risk for postherpetic neuralgia and may benefit from more aggressive pain management 6

• Consider long-term suppressive antiviral therapy in patients with recurrent or chronic active VZV infection contributing to ongoing complications 9