What is the recommended treatment for herpes zoster ophthalmicus?

Treatment of Herpes Zoster Ophthalmicus

Initiate oral antiviral therapy immediately with valacyclovir 1000 mg three times daily for 7 days, ideally within 72 hours of rash onset, to prevent vision-threatening complications and reduce post-herpetic neuralgia. 1

First-Line Antiviral Therapy

The cornerstone of treatment is systemic antiviral medication started as early as possible:

• Valacyclovir 1000 mg orally three times daily for 7 days is the preferred regimen recommended by the American Academy of Ophthalmology for immunocompetent adults 1

• Alternative oral antivirals with equivalent efficacy include:

  • Acyclovir 800 mg orally five times daily for 7 days 1
  • Famciclovir 500 mg orally three times daily for 7 days 1

• Treatment duration of 7 days is sufficient for most immunocompetent patients, as extending to 14 days shows no additional benefit 2

• Timing is critical: Antivirals are most effective when started within 72 hours of rash onset to prevent ocular complications and reduce post-herpetic neuralgia 3, 4

• Early treatment reduces late ocular inflammatory complications from 50-71% in untreated patients to approximately 29% 2

Adjunctive Topical Therapy

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

• Topical antivirals alone are not effective for varicella zoster virus conjunctivitis and should not be used as monotherapy 1

• Ganciclovir 0.15% gel or trifluridine 1% solution may be considered as additive treatment only in unresponsive patients 1

Critical Corticosteroid Precautions

• Topical corticosteroids must be completely avoided during active epithelial viral infection as they potentiate viral replication and worsen the infection 1

• Corticosteroids may only be considered for inflammatory complications (such as subepithelial infiltrates causing blurred vision) without epithelial disease and must be under direct ophthalmologist supervision 1

• When corticosteroids are used, choose formulations with poor ocular penetration to minimize risk of elevated intraocular pressure and cataract formation 1

Special Population Considerations

• Immunocompromised patients require more aggressive antiviral therapy with potential dose adjustments and prolonged treatment based on clinical response 1

• Patients with impaired renal clearance require dose adjustments of systemic antivirals to prevent toxicity 1

Mandatory Follow-Up Protocol

• Schedule follow-up within 1 week of treatment initiation 1

• Follow-up must include:

  • Interval history 1
  • Visual acuity measurement 1
  • Slit-lamp biomicroscopy 1

• For patients on corticosteroid therapy, monitor intraocular pressure regularly and perform pupillary dilation to evaluate for glaucoma and cataract 1

Monitoring for Complications

Watch for these potential ocular complications requiring ophthalmology referral:

• Pseudodendrites, keratitis, corneal scarring, corneal vascularization 1
• Iritis/uveitis, sectoral iris atrophy, secondary glaucoma 1
• Late sequelae including dry eye, corneal anesthesia with neurotrophic keratitis 1
• Panuveitis, acute retinal necrosis (ARN), progressive outer retinal necrosis (PORN) 4

Prevention

• The CDC strongly recommends recombinant zoster vaccine for all immunocompetent patients aged 50 years and older, which has 96% efficacy in preventing herpes zoster and its complications 1