Initial Treatment and Management of Herpes Zoster Ophthalmicus
Immediate Antiviral Therapy
Start oral antiviral therapy immediately upon diagnosis, ideally within 72 hours of rash onset, with valacyclovir 1000 mg three times daily for 7 days as the preferred regimen. 1
Alternative equally effective oral antiviral regimens include:
- Acyclovir 800 mg five times daily for 7 days 1, 2, 3
- Famciclovir 500 mg three times daily for 7 days 1, 4
The evidence strongly supports that antiviral therapy is most effective when initiated within 48-72 hours of rash onset to prevent ocular complications and reduce disease severity. 5, 6 The American Academy of Ophthalmology guidelines prioritize these three oral antivirals as equivalent first-line options for immunocompetent adults. 1
Dose Adjustments for Special Populations
For patients with renal impairment (creatinine clearance <50 mL/min), reduce antiviral doses according to renal function to prevent toxicity. 1, 2
Immunocompromised patients require more aggressive antiviral therapy with potentially higher doses, longer duration, or consideration of intravenous acyclovir 5-10 mg/kg every 8 hours for severe disease. 1, 7
Topical Adjunctive Therapy
Apply topical antibiotics to vesicular skin lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1
Avoid topical antivirals as monotherapy - they have not been shown to be helpful in treating VZV conjunctivitis alone, though ganciclovir 0.15% gel or trifluridine 1% solution may be added in unresponsive cases. 1
Critical Corticosteroid Precautions
Never use topical corticosteroids during active epithelial viral infection as they potentiate viral replication and worsen the infection. 1
Corticosteroids may only be considered for inflammatory complications (subepithelial infiltrates, uveitis) after epithelial disease has resolved and only under direct ophthalmologist supervision. 1 When used, prefer formulations with poor ocular penetration to minimize risks of elevated intraocular pressure and cataract formation. 1
Mandatory Ophthalmology Referral
Refer all patients with suspected herpes zoster ophthalmicus to an ophthalmologist immediately for comprehensive evaluation including slit-lamp biomicroscopy to assess for:
- Pseudodendrites and keratitis 1
- Corneal scarring and vascularization 1
- Iritis/uveitis and sectoral iris atrophy 1
- Secondary glaucoma 1
- Acute retinal necrosis or progressive outer retinal necrosis 6
Follow-Up Protocol
Schedule follow-up within 1 week of treatment initiation including interval history, visual acuity measurement, and slit-lamp biomicroscopy. 1
For patients on corticosteroid therapy, monitor intraocular pressure at each visit and perform pupillary dilation to evaluate for glaucoma and cataract. 1
Monitor for late sequelae including dry eye, corneal anesthesia with neurotrophic keratitis, and postherpetic neuralgia, which may require ongoing management. 1
Prevention
Strongly recommend recombinant zoster vaccine for all immunocompetent patients aged 50 years and older (96% efficacy in preventing herpes zoster and its complications). 1, 8
Common Pitfalls to Avoid
- Delayed treatment beyond 72 hours significantly reduces antiviral efficacy in preventing ocular complications 5, 6
- Using topical corticosteroids during active epithelial infection will worsen the disease 1
- Failing to adjust antiviral doses in renal impairment risks drug toxicity 1
- Missing the diagnosis in immunocompromised or diabetic patients who may present atypically and experience more severe disease with recurrence 9
- Inadequate follow-up missing chronic complications like neurotrophic keratitis or persistent inflammation 1