Treatment for Shingles in the Eye (Herpes Zoster Ophthalmicus)
Start oral valacyclovir 1000 mg three times daily for 7 days immediately upon diagnosis, and arrange urgent ophthalmology referral within 24 hours while continuing antiviral therapy. 1, 2
Immediate Antiviral Therapy
First-line treatment is oral valacyclovir 1000 mg three times daily for 7 days, which is preferred due to superior bioavailability and simpler dosing compared to acyclovir. 1, 2, 3 The American Academy of Ophthalmology recommends starting antivirals immediately—do not delay treatment while waiting for ophthalmology consultation. 2
Alternative oral antiviral regimens include:
- Acyclovir 800 mg five times daily for 7 days 1, 2, 4
- Famciclovir 500 mg three times daily for 7 days 1, 2
Treatment is most effective when initiated within 72 hours of rash onset, though evidence suggests valacyclovir may still provide benefit when started later than 72 hours. 1, 5 Adjust dosing for renal impairment—exercise caution in patients with reduced creatinine clearance. 1, 3
Mandatory Ophthalmology Involvement
All cases of facial shingles near or involving the eye require immediate involvement of an experienced ophthalmologist. 2 Herpes zoster ophthalmicus can cause serious vision-threatening complications including:
- Pseudodendrites and keratitis 1, 2
- Corneal scarring and vascularization 1, 2
- Iritis/uveitis and sectoral iris atrophy 1, 2
- Secondary glaucoma 1, 2
- Neurotrophic keratitis from corneal anesthesia 1, 2
Adjunctive Topical Therapy
Apply topical antibiotics to vesicles to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1, 2 This has high-strength evidence supporting its use. 1
Avoid topical corticosteroids during active epithelial viral infection as they can potentiate the infection. 1, 2 However, for inflammatory complications without epithelial disease (such as subepithelial infiltrates causing blurred vision and photophobia), topical corticosteroids at the minimum effective dose may be considered under ophthalmologist supervision only. 1, 2
Topical antivirals alone are not helpful for VZV conjunctivitis and should not be used as monotherapy, as they do not reach the site of viral reactivation in the ganglia. 1, 2 Ganciclovir 0.15% gel or trifluridine 1% solution may be used as additive treatment in unresponsive patients. 1, 2
Special Populations
Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments based on clinical response. 1, 2 High-dose IV acyclovir remains the treatment of choice for VZV infections in severely compromised hosts. 2 Patients with chronic or recalcitrant disease may require prolonged treatment beyond the standard 7-day course. 1, 2
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation, including: 1, 2
- Interval history 1, 2
- Visual acuity measurement 1, 2
- Slit-lamp biomicroscopy 1, 2
- Assessment for resolution of acute symptoms 2
- Evaluation for development of complications 2
- Intraocular pressure measurement if on corticosteroid therapy 1, 2
Critical Pitfalls to Avoid
Do not delay antiviral treatment waiting for ophthalmology consultation—start oral antivirals immediately while arranging urgent referral. 2 The window for maximum antiviral efficacy is narrow. 1
Monitor for late sequelae including dry eye and neurotrophic keratitis, which may develop months after the acute infection and require ongoing monitoring. 1, 2 These complications can occur despite appropriate acute treatment. 1
Never use topical antivirals as monotherapy, as they are ineffective for treating the underlying ganglionic viral reactivation. 2