Treatment of Herpes Zoster Ophthalmicus
All patients with herpes zoster ophthalmicus require immediate oral antiviral therapy, with valacyclovir 1000 mg three times daily for 7 days as the preferred first-line treatment in immunocompetent adults, initiated ideally within 72 hours of rash onset. 1
Antiviral Therapy Selection
Immunocompetent Patients
- Valacyclovir 1000 mg three times daily for 7 days is the recommended first-line oral antiviral regimen 1
- Alternative oral regimens include:
- Treatment must be initiated within 72 hours of rash onset for maximum efficacy in preventing ocular complications 2, 3
- Continue treatment for a minimum of 7-10 days 4
Immunocompromised Patients
- Complicated herpes zoster ophthalmicus (multi-dermatomal, ophthalmic, visceral, or disseminated) requires intravenous acyclovir 4
- Immunocompromised patients need more aggressive antiviral therapy with potential dose adjustments based on clinical response 1
- Patients with chronic or recalcitrant disease may require prolonged treatment 1
Renal Impairment Considerations
- Exercise caution and adjust antiviral doses in patients with impaired renal clearance 1
Adjunctive Topical Management
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
Topical Antiviral Role
- Topical antivirals alone are not effective for varicella zoster virus conjunctivitis and should not be used as monotherapy 1
- Ganciclovir 0.15% gel and trifluridine 1% solution may be considered as additive treatment only in unresponsive patients 1
Corticosteroid Management
Critical 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 without epithelial disease and must be under direct ophthalmologist supervision 1
- When used, prefer formulations with poor ocular penetration to minimize risk of elevated intraocular pressure and cataract formation 1
- For subepithelial infiltrates causing blurring, photophobia, and decreased vision, use topical corticosteroids at the minimum effective dose 1
Follow-Up Protocol
Initial Follow-Up (Within 1 Week)
- Schedule follow-up within 1 week of treatment initiation 1
- Include interval history, visual acuity measurement, and slit-lamp biomicroscopy 1
Ongoing Monitoring
- For patients on corticosteroid therapy, measure intraocular pressure regularly and perform pupillary dilation to evaluate for glaucoma and cataract 1
- Monitor for potential ocular complications including pseudodendrites, keratitis, corneal scarring, corneal vascularization, iritis/uveitis, sectoral iris atrophy, and secondary glaucoma 1
- Monitor for late sequelae including dry eye and corneal anesthesia with neurotrophic keratitis 1
Immunosuppressive Therapy Considerations
- In immunosuppressed patients with ongoing VZV infection, immunosuppressive therapy should be discontinued in severe cases of disseminated VZV 4
- If immunosuppression has been withheld, it may be reasonable to restart after the patient has commenced anti-VZV therapy and the skin vesicles have resolved 4
Evidence Quality Notes
The evidence demonstrates that oral acyclovir significantly reduces active ocular disease at 6 months and modifies long-term complications 5, and reduces the incidence and severity of dendritiform keratopathy, stromal keratitis, and uveitis 6. However, a Cochrane review found very low certainty evidence when comparing valacyclovir to acyclovir, with uncertainty about relative benefits despite valacyclovir's improved bioavailability 7. Despite this uncertainty, valacyclovir remains the preferred agent based on guideline recommendations due to its superior pharmacokinetics and dosing convenience 1.