What is the best treatment approach for a patient with herpes zoster (shingles) around the eye?

Treatment of Herpes Zoster Around the Eye

For herpes zoster ophthalmicus (HZO), initiate oral valacyclovir 1000 mg three times daily for 7 days, starting as soon as possible and ideally within 72 hours of rash onset. 1, 2, 3

Antiviral Therapy

Oral antiviral therapy is the cornerstone of treatment for HZO and should be started immediately upon diagnosis. 1, 2

First-Line Regimens (Choose One):

• Valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability and convenient dosing) 1, 2, 3
• Acyclovir 800 mg five times daily for 7 days 1, 2
• Famciclovir 500 mg three times daily for 7 days 1, 2

Key Timing Considerations:

• Treatment is most effective when initiated within 48-72 hours of rash onset 1, 3
• However, treatment may still provide benefit even when started beyond 72 hours, particularly for pain reduction 4
• Do not withhold treatment if the patient presents after 72 hours, especially with ocular involvement 4

Special Populations:

• Immunocompromised patients may require more aggressive therapy with dose adjustments and prolonged treatment duration 1, 2
• Patients with impaired renal function require dose adjustment based on creatinine clearance 2, 3

Adjunctive Topical Therapy

Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection, which can lead to severe complications including cicatricial ectropion. 1, 2

Critical Point on Topical Antivirals:

• Topical antivirals alone are NOT effective for VZV conjunctivitis and should not be used as monotherapy 1, 2
• They may be considered as additive treatment only in unresponsive cases 1, 2

Corticosteroid Management

Topical corticosteroids must be AVOIDED during active epithelial viral infection as they potentiate viral replication and worsen the infection. 1, 2

When Corticosteroids May Be Considered:

• Only for inflammatory complications WITHOUT epithelial disease 1, 2
• Must be under direct ophthalmologist supervision 2
• For subepithelial infiltrates causing blurring, photophobia, and decreased vision, use minimum effective dose 1, 2
• Prefer formulations with poor ocular penetration (fluorometholone or loteprednol) to minimize risk of elevated intraocular pressure and cataract formation 1

Follow-Up Protocol

Schedule follow-up within 1 week of treatment initiation. 1, 2

Each Visit Should Include:

• Interval history 1, 2
• Visual acuity measurement 1, 2
• Slit-lamp biomicroscopy 1, 2
• Intraocular pressure measurement if patient is on corticosteroid therapy 2
• Pupillary dilation to evaluate for glaucoma and cataract in patients on corticosteroids 2

Monitor for Ocular Complications:

• Pseudodendrites 1, 2
• Keratitis and corneal scarring 1, 2
• Corneal vascularization 1, 2
• Iritis/uveitis 1, 2
• Sectoral iris atrophy 1, 2
• Secondary glaucoma 1, 2

Long-Term Monitoring:

• Late sequelae may include dry eye and corneal anesthesia with neurotrophic keratitis, requiring ongoing monitoring 2

Common Pitfalls to Avoid

• Do not delay antiviral therapy waiting for laboratory confirmation - treat based on clinical presentation 1, 2
• Do not use topical corticosteroids during active epithelial disease - this is a critical error that worsens infection 1, 2
• Do not rely on topical antivirals alone - they are ineffective as monotherapy 1, 2
• Do not forget to adjust antiviral doses in renal impairment - this can lead to toxicity 2, 3
• Do not assume treatment is futile after 72 hours - pain reduction benefits may still occur 4

Prevention

Strongly recommend recombinant zoster vaccine (RZV) for all immunocompetent patients aged 50 years and older to prevent herpes zoster and its complications (96% efficacy). 1, 2

• RZV is preferred over zoster vaccine live (ZVL) due to superior efficacy (96% vs 70%) 1
• RZV can be given to immunocompetent patients who previously received ZVL 1