Treatment for Herpes Zoster Near the Eye
Start oral antiviral therapy immediately with valacyclovir 1000 mg three times daily for 7 days, ideally within 72 hours of rash onset, to prevent vision-threatening complications. 1
First-Line Antiviral Therapy
The American Academy of Ophthalmology recommends oral antivirals as the cornerstone of treatment for herpes zoster ophthalmicus (HZO). 1 You have three equally effective options:
- Valacyclovir 1000 mg three times daily for 7 days 1, 2
- Acyclovir 800 mg five times daily for 7 days 1
- Famciclovir 500 mg three times daily for 7 days 1, 3
Timing is critical: Treatment must be initiated within 72 hours of rash onset to effectively prevent ocular complications and reduce post-herpetic neuralgia. 1, 2, 4 After 72 hours, efficacy is not established. 2, 4
The 7-day treatment duration is sufficient for immunocompetent patients—extending beyond 7 days provides no additional benefit. 5
Special Population Considerations
Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments and prolonged treatment based on clinical response. 1
Patients with impaired renal clearance need dose adjustments to prevent toxicity. 1 This is particularly important as all three antivirals are renally excreted.
Adjunctive Topical Therapy
Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1
Avoid topical antivirals alone—they have not been shown to be effective for VZV conjunctivitis. 1 However, ganciclovir 0.15% gel or trifluridine 1% solution may be added in unresponsive cases. 1
Corticosteroid Management: Critical Timing
Never use topical corticosteroids if epithelial viral infection is present—they will potentiate the infection. 1
Consider corticosteroids only under ophthalmologist supervision for inflammatory complications (subepithelial infiltrates, uveitis) after epithelial disease has resolved. 1 Use the minimum effective dose. 1
Mandatory Monitoring Protocol
Schedule follow-up within 1 week of treatment initiation. 1 This visit must include:
- Interval history 1
- Visual acuity measurement 1
- Slit-lamp biomicroscopy 1
- Intraocular pressure measurement if on corticosteroids 1
Monitor for these vision-threatening complications:
- Pseudodendrites and dendritic ulcers 1
- Keratitis with corneal scarring or vascularization 1
- Iritis/uveitis 1
- Sectoral iris atrophy 1
- Secondary glaucoma 1
Late Sequelae Requiring Ongoing Surveillance
Continue monitoring for:
- Dry eye syndrome 1
- Corneal anesthesia with neurotrophic keratitis 1
- Post-herpetic neuralgia (reduced to 13% with early antiviral treatment versus 50-71% untreated) 5
Common Pitfalls to Avoid
Do not delay treatment waiting for ophthalmology consultation—start oral antivirals immediately if HZO is suspected, then refer. 4
Do not use famciclovir for shingles in the eye according to FDA labeling, as safety and efficacy have not been established specifically for ophthalmic zoster. 3 However, the American Academy of Ophthalmology includes it as a recommended option. 1
Do not assume the infection is limited to skin—up to 29% of patients develop late ocular inflammatory complications even with treatment. 5
Do not stop monitoring after acute phase—late complications can develop months after initial infection. 1