What is the treatment for herpes zoster (shingles) in the eye?

Treatment for Herpes Zoster in the Eye (Herpes Zoster Ophthalmicus)

Oral antiviral therapy is the cornerstone of treatment for herpes zoster ophthalmicus (HZO), with valacyclovir 1000 mg three times daily for 7 days being the recommended first-line treatment. 1

Antiviral Therapy Options

• Valacyclovir 1000 mg three times daily for 7 days is the preferred oral antiviral for immunocompetent adults with HZO 1
• Alternative oral antivirals include:
  • Acyclovir 800 mg five times daily for 7 days 1
  • Famciclovir 500 mg three times daily for 7 days 1
• Antiviral therapy is most effective when started within 72 hours after the onset of the rash 2, 3
• Immunocompromised patients may require more aggressive antiviral therapy with dose adjustments 1

Management of Ocular Complications

• Consult with an ophthalmologist for thorough evaluation including slit-lamp examination for all suspected cases of HZO 1, 3
• Topical antibiotics are recommended to prevent secondary bacterial infection of vesicles that undergo necrosis 1
• Topical antivirals alone are not effective for treating VZV conjunctivitis but may be used as adjunctive therapy in unresponsive cases 1
• Potential ocular complications requiring monitoring include:
  • Pseudodendrites, keratitis, corneal scarring 1
  • Corneal vascularization, iritis/uveitis 1
  • Sectoral iris atrophy and secondary glaucoma 1

Corticosteroid Considerations

• Topical corticosteroids should be avoided in epithelial viral infections as they can potentiate the infection 1
• For inflammatory complications without epithelial disease, corticosteroids may be considered under ophthalmologist supervision 4
• In cases with subepithelial infiltrates causing blurring, photophobia, and decreased vision, topical corticosteroids at the minimum effective dose may be considered 4

Follow-up Protocol

• Schedule follow-up within 1 week of treatment initiation 1
• Follow-up examination should include:
  • Interval history and symptom assessment 1
  • Visual acuity measurement 1
  • Slit-lamp biomicroscopy 1
  • Intraocular pressure measurement if on corticosteroid therapy 4

Special Considerations

• Patients with chronic or recalcitrant disease may require prolonged antiviral treatment with dose adjustments based on clinical response 1
• Monitor for late sequelae including dry eye and corneal anesthesia with neurotrophic keratitis 1
• Post-herpetic neuralgia is a common complication that may require additional management with tricyclic antidepressants, anticonvulsants, or analgesics 2
• Adjust antiviral dosing in patients with impaired renal function 1

Common Pitfalls to Avoid

• Delaying antiviral therapy beyond 72 hours significantly reduces effectiveness 3, 5
• Failing to refer to an ophthalmologist when ocular involvement is present 3
• Using topical corticosteroids without antiviral coverage in active epithelial disease 1
• Discontinuing treatment prematurely before resolution of active disease 1
• Inadequate follow-up for potential complications 1

Early treatment with oral antivirals has been shown to reduce the severity of skin eruption, the incidence and severity of ocular complications, and the intensity of postherpetic neuralgia 6.