Acyclovir Dosage for Ocular Herpes
For HSV ocular disease (herpes simplex keratitis/uveitis), use oral acyclovir 400 mg five times daily for 7-10 days, or alternatively valacyclovir 500 mg two to three times daily for 7-10 days, which offers simpler dosing with equivalent efficacy.
HSV Ocular Disease (Herpes Simplex Keratitis/Uveitis)
Acute Treatment Regimen
Oral acyclovir 400 mg five times daily for 7-10 days is the standard approach for HSV ocular infections, though this specific dosing is extrapolated from general HSV treatment guidelines 1
Valacyclovir 500 mg two to three times daily for 7-10 days is recommended by the American Academy of Ophthalmology for HSV uveitis flare-ups and offers superior convenience with comparable efficacy 2
Treatment should be initiated as early as possible when HSV ocular disease is suspected, as prompt therapy reduces complications and improves outcomes 2
Important Treatment Considerations
Avoid topical corticosteroids in HSV epithelial keratitis as they potentiate viral replication and worsen infection 2
Topical corticosteroids may be used with concurrent oral antiviral therapy for HSV stromal keratitis, where inflammation is the primary pathology 2
Topical antivirals (trifluridine or ganciclovir) can be used adjunctively, but trifluridine causes epithelial toxicity if used beyond 2 weeks 2
Follow-up Protocol
All patients require follow-up within 1 week consisting of interval history, visual acuity measurement, and slit-lamp biomicroscopy to assess treatment response 2
Monitor for late sequelae including dry eye, corneal anesthesia, and neurotrophic keratitis 2
Long-term Suppressive Therapy
Lower doses of oral antivirals (acyclovir 400 mg twice daily or valacyclovir 500 mg once daily) should be considered for prophylaxis in patients with frequent recurrent HSV ocular disease 2
Adjust dosing based on clinical response and recurrence frequency 2
Herpes Zoster Ophthalmicus (Shingles Affecting the Eye)
Acute Treatment Regimen
Oral acyclovir 800 mg five times daily for 7 days is the established regimen for herpes zoster ophthalmicus when initiated within 72 hours of skin eruption 3, 4, 5
A 7-day course is sufficient—extending treatment to 14 days provides no additional benefit 3
Valacyclovir 1000 mg three times daily for 7 days is an alternative that accelerates pain resolution compared to acyclovir while offering simpler dosing 6
Clinical Benefits of Early Treatment
Treatment within 72 hours significantly reduces:
Active ocular disease at 6 months is significantly reduced with acyclovir treatment 5
Pain Management Expectations
Acyclovir reduces acute phase pain, especially when started within 72 hours 4
Valacyclovir accelerates overall pain resolution (median 38 days vs 51 days with acyclovir) and reduces 6-month pain persistence (19.3% vs 25.7%) 6
Only 13% of treated patients experience postherpetic neuralgia requiring analgesics 3
Special Populations
Immunocompromised Patients
May require more aggressive therapy with higher doses or IV administration 1, 2
Caution with renal impairment—dose adjustment necessary based on creatinine clearance 2
Severe Disease
- IV acyclovir 5-10 mg/kg every 8 hours for 5-7 days should be used for severe ocular disease requiring hospitalization or with systemic complications 1
Neonates
- Immediate pediatric consultation required due to risk of life-threatening systemic HSV infection 2
Critical Pitfalls to Avoid
Do not use topical corticosteroids alone in suspected HSV epithelial disease without concurrent systemic antiviral therapy 2
Do not delay treatment waiting for laboratory confirmation—clinical diagnosis should prompt immediate therapy 4, 5
Do not extend acyclovir 800 mg five times daily beyond 7 days for herpes zoster ophthalmicus, as it provides no additional benefit 3
Do not use topical trifluridine for more than 2 weeks due to epithelial toxicity 2