Treatment for Herpes Zoster Near the Eye
Initiate oral valacyclovir 1000 mg three times daily for 7 days immediately upon diagnosis of herpes zoster ophthalmicus, ideally within 72 hours of rash onset, and refer urgently to an ophthalmologist for comprehensive evaluation and management of potential ocular complications. 1, 2
First-Line Antiviral Therapy
Valacyclovir is the preferred oral antiviral due to superior bioavailability and simpler dosing compared to acyclovir 1:
- Valacyclovir 1000 mg three times daily for 7 days 1, 3
- Alternative: Acyclovir 800 mg five times daily for 7 days 1, 2
- Alternative: Famciclovir 500 mg three times daily for 7 days 1, 2, 4
Timing is critical: Antiviral therapy is most effective when initiated within 72 hours of rash onset to prevent ocular complications and reduce the severity of postherpetic neuralgia 5, 6, 7. However, treatment should still be started even if presenting beyond 72 hours, as late treatment may still provide benefit 8.
Mandatory Ophthalmology Referral
Immediate involvement of an experienced ophthalmologist is strongly recommended for all cases of herpes zoster ophthalmicus 1, 2. The ophthalmologist should perform:
- Slit-lamp biomicroscopy to assess for ocular involvement 1, 2
- Visual acuity measurement 1, 2
- Evaluation for complications including pseudodendrites, keratitis, corneal scarring, uveitis, sectoral iris atrophy, and secondary glaucoma 1, 2
Adjunctive Therapy
Topical antibiotics should be applied to prevent secondary bacterial infection of vesicles that undergo necrosis, which can lead to severe complications including cicatricial ectropion 2.
Topical antivirals alone are not helpful for VZV conjunctivitis, but ganciclovir 0.15% gel or trifluridine 1% solution may be used as additive treatment in unresponsive patients 1, 2.
Avoid topical corticosteroids in the presence of epithelial viral infections as they can potentiate the infection 2. However, for inflammatory complications without epithelial disease, corticosteroids may be considered under ophthalmologist supervision 2.
Special Populations
Immunocompromised patients (including HIV-infected individuals) may require more aggressive antiviral therapy with dose adjustments based on clinical response 1, 2.
Patients with renal impairment require dose adjustments of valacyclovir based on creatinine clearance 3:
- CrCl 30-49 mL/min: Reduce dosing frequency
- CrCl 10-29 mL/min: Further dose reduction required
- CrCl <10 mL/min: Significant dose reduction necessary
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation 1, 2, including:
- Interval history 1, 2
- Visual acuity measurement 1, 2
- Slit-lamp biomicroscopy 1, 2
- Assessment for resolution of acute symptoms and development of complications 1
- Intraocular pressure measurement if on corticosteroid therapy 2
Monitoring for Complications
Monitor for late sequelae including 1, 2:
- Dry eye and corneal anesthesia with neurotrophic keratitis
- Postherpetic neuralgia (most debilitating complication) 7
- Chronic ocular inflammation and vision loss 5
Patients with chronic or recalcitrant disease may require prolonged antiviral treatment with dose adjustments according to clinical response 1, 2.
Prevention
Strongly recommend recombinant zoster vaccine (RZV) for immunocompetent patients aged 50 years and older to prevent herpes zoster and its complications 9. The vaccine is also recommended for immunocompromised patients aged 19 years and older 9.
Critical Pitfalls to Avoid
- Do not delay treatment waiting for ophthalmology consultation—start antivirals immediately while arranging urgent referral 5, 6
- Do not use topical corticosteroids without ophthalmologist supervision and confirmation of no epithelial disease 2
- Do not assume absence of ocular involvement without formal ophthalmologic examination, as complications can be sight-threatening 5, 7
- Do not forget renal dose adjustments for valacyclovir in patients with impaired kidney function 2, 3