What is the treatment for herpes zoster ophthalmicus in an adult patient over 50 with potential compromised immunity?

Treatment for Herpes Zoster Ophthalmicus

Initiate oral antiviral therapy immediately—ideally within 72 hours of rash onset—with acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg three times daily for 7 days, or famciclovir 500 mg three times daily for 7 days, combined with urgent ophthalmologic consultation and intensive ocular supportive care. 1, 2, 3

Systemic Antiviral Therapy

• Start oral antivirals within 72 hours of rash onset to prevent ocular complications and reduce the severity of skin eruption, late ocular manifestations, and postherpetic neuralgia 4, 3, 5

• Standard dosing regimens include:

  • Acyclovir 800 mg five times daily for 7 days 1, 4
  • Valacyclovir 1000 mg every 8 hours for 7 days 1
  • Famciclovir 500 mg three times daily for 7 days 1

• A 7-day course is sufficient for immunocompetent patients—extending treatment to 14 days provides no additional benefit in reducing skin lesions, ocular complications, or postherpetic neuralgia 4

• Immunocompromised patients require more aggressive treatment, potentially including intravenous antivirals, due to higher risk for disseminated disease 2

Immediate Ophthalmologic Management

• Urgent ophthalmology referral is mandatory for all patients with suspected ocular involvement, as approximately 50% of HZO patients develop ocular disease and up to 25% develop chronic or recurrent complications 5

• Daily ophthalmological review during acute illness is necessary to monitor for evolving complications 2

Ocular Surface Protection

• Apply non-preserved ocular lubricants (hyaluronate or carmellose eye drops) every 2 hours throughout the acute illness to prevent corneal exposure and desiccation 2

• Daily ocular hygiene must be performed by an ophthalmologist or ophthalmically trained nurse 2

• For unconscious patients, use polyethylene film to create a moisture chamber and prevent corneal exposure 2

Topical Therapy

• Consider topical corticosteroid drops (non-preserved dexamethasone 0.1% twice daily) to reduce ocular surface damage, but only under ophthalmologic supervision 2

• Administer broad-spectrum topical antibiotics (moxifloxacin drops four times daily) if corneal fluorescein staining or ulceration is present to prevent secondary bacterial infection 2

• Topical antivirals alone are not helpful for VZV conjunctivitis but may be used as additive treatment in unresponsive patients 1

Management of Specific Ocular Complications

Keratitis and Uveitis

• Topical corticosteroids may be necessary for stromal keratitis or uveitis, but must be used in conjunction with systemic antiviral therapy to prevent viral replication 1

• Use corticosteroids with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) when possible to minimize risk of elevated intraocular pressure and cataract formation 1

• Taper corticosteroids slowly to the minimum effective dose to prevent rebound inflammation 1

Monitoring Requirements

• Regular follow-up visits should include interval history, visual acuity measurement, intraocular pressure measurement, and slit-lamp biomicroscopy 1

• Monitor for late ocular inflammatory complications, which occur in approximately 29% of treated patients versus 50-71% of untreated patients 4

Critical Timing Considerations

• The 72-hour window is crucial—antiviral efficacy in preventing ocular involvement drops significantly when treatment is delayed beyond this timeframe 6, 3, 5

• Even with prompt treatment, 13% of patients may still experience postherpetic neuralgia, though it is typically less severe and rarely requires analgesics 4

Common Pitfalls to Avoid

• Never delay treatment waiting for ophthalmology consultation—start oral antivirals immediately while arranging urgent referral 3, 5

• Do not use topical corticosteroids without concurrent systemic antiviral therapy, as steroids potentiate HSV infection and can worsen VZV disease 1

• Avoid topical trifluridine for more than 2 weeks as it inevitably causes epithelial toxicity 1

• Do not assume the absence of ocular symptoms means no ocular involvement—occult disease may be present and requires ophthalmologic examination 5

Special Population Considerations

Immunocompromised Patients (Age >50 with Potential Compromised Immunity)

• Consider intravenous acyclovir for severely immunocompromised patients or those with disseminated disease 2

• Prolonged treatment may be necessary for patients with chronic disease, with dose adjustment according to clinical response 1

• Exercise caution in patients with impaired renal clearance—adjust antiviral dosing accordingly 1

Prevention

• Recommend recombinant zoster vaccine (RZV/Shingrix) for prevention in adults aged 50 years and older, with 96% efficacy compared to 70% for the older live vaccine 2

• Vaccination is appropriate even after an episode of HZO, as natural immunity does not provide reliable protection against recurrence 2