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

Treatment for Shingles Near 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. 1, 2

Immediate Antiviral Therapy

Initiate systemic antiviral treatment as soon as herpes zoster ophthalmicus is suspected—do not delay waiting for ophthalmology consultation. 2 The antiviral medications are most effective when started within 72 hours of rash onset. 3, 4

First-Line Treatment Options:

• Valacyclovir 1000 mg orally three times daily for 7 days (preferred due to superior bioavailability and simpler dosing) 1, 2, 5
• Acyclovir 800 mg orally five times daily for 7 days (alternative option) 1, 2, 4
• Famciclovir 500 mg orally three times daily for 7 days (alternative option) 1, 2, 5

Evidence from high-quality trials demonstrates that valacyclovir and famciclovir provide significant reduction in herpes-zoster-associated pain compared to acyclovir, with valacyclovir showing 36% risk reduction in pain at 21-30 days (number needed to treat = 3) and famciclovir showing 46% reduction at 28-30 days. 5 A 7-day course is sufficient—prolonging treatment beyond 7 days provides no additional benefit. 4

Mandatory Ophthalmology Referral

All cases of herpes zoster ophthalmicus require immediate involvement of an experienced ophthalmologist. 1, 2 This is non-negotiable because serious vision-threatening complications can develop, including:

• Pseudodendritic keratitis and corneal ulceration 6, 2
• Corneal scarring and neovascularization 6, 2
• Uveitis and sectoral iris atrophy 2
• Secondary glaucoma 2
• Neurotrophic keratitis from corneal anesthesia 6, 2

The ophthalmologist will perform slit-lamp biomicroscopy, visual acuity measurement, and comprehensive assessment for complications. 1

Adjunctive Topical Therapy

Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1, 2

Avoid topical corticosteroids during active epithelial viral infection as they potentiate viral replication. 1, 2 Corticosteroids may be considered later under ophthalmologist supervision for inflammatory complications without epithelial disease. 2

Topical antivirals alone are not helpful for VZV conjunctivitis because they do not reach the site of viral reactivation in the ganglia. 2 However, ganciclovir 0.15% gel or trifluridine 1% solution may be used as additive treatment in unresponsive patients under ophthalmology guidance. 1, 2

Special Populations

Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments based on clinical response. 1, 2 This includes HIV-infected individuals, those on chemotherapy, or chronic corticosteroid users. 6, 3 High-dose IV acyclovir remains the treatment of choice for severely compromised hosts. 2

Adjust dosing for renal impairment and exercise caution in patients with impaired renal clearance. 2

Follow-Up Protocol

Schedule follow-up within 1 week of treatment initiation to assess: 2

• Interval history and visual acuity measurement 2
• Slit-lamp biomicroscopy 2
• Resolution of acute symptoms 2
• Development of complications 2
• Intraocular pressure if on corticosteroid therapy 2

Monitor for late sequelae including dry eye and neurotrophic keratitis, which may develop months after acute infection. 2

Critical Pitfalls to Avoid

• Do not delay antiviral treatment waiting for ophthalmology consultation—start immediately while arranging urgent referral 2
• Do not use topical antivirals as monotherapy 2
• Do not assume resolution means cure—late ocular inflammatory complications occur in approximately 29% of treated patients at 6 months 4
• Do not stop monitoring early—prolonged treatment may be necessary for chronic or recalcitrant disease 2

Prevention

Strongly recommend recombinant zoster vaccine (RZV) for all immunocompetent patients aged 50 years and older to prevent herpes zoster and its complications. 6, 1 RZV is preferred over live zoster vaccine due to 96% efficacy versus 70%. 6 The vaccine is also recommended for immunocompromised patients aged 19 years and older. 1