Treatment for Herpes Zoster with Ocular Involvement
Initiate oral valacyclovir 1000 mg three times daily for 7 days immediately upon diagnosis and arrange urgent ophthalmology referral within 24 hours. 1, 2, 3
Immediate Antiviral Therapy
Start systemic antiviral treatment as soon as herpes zoster ophthalmicus is suspected, without waiting for ophthalmology consultation. 3 Antiviral medications are most effective when initiated within 72 hours of rash onset, though treatment should not be withheld if presenting later. 4, 5
First-Line Antiviral Options
Valacyclovir 1000 mg orally three times daily for 7 days is the preferred agent due to superior bioavailability and simpler dosing compared to acyclovir. 1, 2, 3, 6
Alternative regimens include:
A 7-day course is sufficient; extending treatment to 14 days provides no additional benefit. 8
Renal Dosing Adjustments
Adjust antiviral dosing in patients with impaired renal clearance to prevent acute renal failure, particularly in those with underlying renal disease. 1, 3, 6
For valacyclovir in herpes zoster with creatinine clearance 30-49 mL/min: 1000 mg every 12 hours; CrCl 10-29 mL/min: 1000 mg every 24 hours; CrCl <10 mL/min: 500 mg every 24 hours. 6
Mandatory Ophthalmology Referral
All cases of herpes zoster ophthalmicus require immediate involvement of an experienced ophthalmologist within 24 hours to assess for vision-threatening complications. 1, 2, 3
Comprehensive Ophthalmologic Assessment
The ophthalmologist must perform slit-lamp biomicroscopy, visual acuity measurement, and assessment for complications including pseudodendritic keratitis, corneal ulceration, uveitis, corneal scarring, neovascularization, and secondary glaucoma. 1, 3
Monitor for additional complications: sectoral iris atrophy, dry eye, corneal anesthesia with neurotrophic keratitis, and post-herpetic neuralgia. 1
Follow-up visit within 1 week of treatment initiation should include interval history, visual acuity measurement, and slit-lamp biomicroscopy. 1
Adjunctive Topical Therapy
Prevention of Secondary Bacterial Infection
- Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1, 2, 3
Topical Antiviral Considerations
- 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
Corticosteroid Management
Avoid topical corticosteroids during active epithelial viral infection as they potentiate viral replication and can worsen the infection. 1, 2, 3
For inflammatory complications without epithelial disease (such as subepithelial infiltrates causing blurring, photophobia, and decreased vision), topical corticosteroids at the minimum effective dose may be considered under ophthalmologist supervision only. 1
Measure intraocular pressure if the patient is on corticosteroid therapy to monitor for steroid-induced glaucoma. 1
Special Populations
Immunocompromised Patients
Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments based on clinical response. 1, 2, 3
This includes HIV-infected individuals, those on chemotherapy, or chronic corticosteroid users. 3
For HIV-infected patients with recurrent orolabial or genital herpes, famciclovir 500 mg twice daily for 7 days is recommended. 7
Kidney Transplant Recipients
- For disseminated or invasive herpes zoster in kidney transplant recipients, use intravenous acyclovir with temporary reduction in immunosuppressive medication until all lesions have scabbed. 9
Common Pitfalls to Avoid
Do not delay antiviral treatment while awaiting ophthalmology consultation—start immediately upon clinical suspicion. 3
Do not use topical corticosteroids in the presence of epithelial disease, as this can lead to corneal perforation and vision loss. 1, 2
Do not assume treatment is futile if presenting after 72 hours—observational data suggest valacyclovir may still be effective when given later than previously thought, though ideally it should be given as soon as possible. 10
Do not overlook late sequelae including dry eye and corneal anesthesia with neurotrophic keratitis, which require ongoing monitoring. 1