Treatment of Herpes Zoster Ophthalmicus
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—do not wait for ophthalmology consultation. 2 Antiviral medications are most effective when initiated within 72 hours of rash onset, though treatment should still be started even if this window has passed. 4, 5
First-Line Oral Antiviral Options:
- Valacyclovir 1000 mg three times daily for 7 days (preferred regimen) 1, 2, 3
- Acyclovir 800 mg five times daily for 7 days 1
- Famciclovir 500 mg three times daily for 7 days 1
A 7-day course is sufficient for immunocompetent patients, as studies show no additional benefit from extending treatment to 14 days. 6 The evidence demonstrates that prompt oral antiviral therapy reduces skin eruption severity, late ocular inflammatory complications (from 50-71% in untreated patients to 29% with treatment), and postherpetic neuralgia incidence (to only 13% of treated patients). 6
Special Population Considerations:
- Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments based on clinical response and may need prolonged treatment. 1, 2
- Patients with renal impairment require dose adjustments: for creatinine clearance 30-49 mL/min, reduce valacyclovir to 1 gram twice daily; for 10-29 mL/min, reduce to 1 gram once daily; for <10 mL/min, reduce to 500 mg once daily. 3
- Kidney transplant recipients with disseminated disease need intravenous acyclovir with temporary reduction in immunosuppression until all lesions have scabbed. 2
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 including pseudodendrites, keratitis, corneal scarring, corneal vascularization, iritis/uveitis, sectoral iris atrophy, secondary glaucoma, panuveitis, acute retinal necrosis, and progressive outer retinal necrosis. 1, 2, 4
The ophthalmologist should perform comprehensive assessment including slit-lamp biomicroscopy, visual acuity measurement, and intraocular pressure measurement if corticosteroids are being considered. 1, 2
Adjunctive Topical Therapy
Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion from conjunctival scarring. 7, 1, 2
Topical antivirals alone (ganciclovir 0.15% gel or trifluridine 1% solution) have not been shown to be helpful in treating varicella zoster virus conjunctivitis and should not be used as monotherapy. 7, 1 They may be considered as additive treatment only in unresponsive patients. 1
Critical Corticosteroid Precautions
Topical corticosteroids must be avoided during active epithelial viral infection as they potentiate viral replication and worsen the infection. 7, 1, 2
Corticosteroids may only be considered for inflammatory complications without epithelial disease and must be under direct ophthalmologist supervision. 1 If subepithelial infiltrates develop causing blurring, photophobia, and decreased vision, topical corticosteroids at the minimum effective dose may be used, preferably with poor ocular penetration formulations (fluorometholone, rimexolone, or loteprednol) to minimize risk of elevated intraocular pressure and cataract formation. 7, 1
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation including interval history, visual acuity measurement, and slit-lamp biomicroscopy. 7, 1
For patients on corticosteroid therapy, monitor intraocular pressure regularly and perform pupillary dilation to evaluate for glaucoma and cataract. 7, 1 Taper corticosteroids slowly to the minimum effective dose once inflammation is controlled. 7
Long-Term Monitoring
Monitor for late sequelae including dry eye, corneal anesthesia with neurotrophic keratitis, and recurrence of subepithelial infiltrates (particularly in patients undergoing photorefractive keratectomy or LASIK). 7, 1
Prevention
Strongly recommend recombinant zoster vaccine (RZV) for all immunocompetent patients aged 50 years and older to prevent herpes zoster and its complications, with 96% efficacy compared to 70% for the older live attenuated vaccine. 7, 2 The CDC preferentially recommends RZV over zoster vaccine live, and it can be given even to patients who previously received the older vaccine. 7