What is the appropriate triage and treatment for an elderly patient with herpes zoster (shingles) involving the orbit and eye, presenting 4 days after onset?

Herpes Zoster Ophthalmicus: Urgent Triage and Treatment Protocol

Immediate Triage Decision

This patient requires same-day urgent ophthalmology consultation within 24 hours and immediate initiation of systemic antiviral therapy. 1, 2 Facial shingles involving the orbit and eye represents herpes zoster ophthalmicus (HZO), a sight-threatening emergency that demands aggressive intervention even at 4 days post-onset.

Immediate Treatment Initiation (Start Today)

Systemic Antiviral Therapy

Start oral antiviral therapy immediately, even though the patient is beyond the ideal 72-hour window—treatment remains beneficial up to 7 days and beyond for ocular involvement 1, 2:

First-line options (choose one):

• Valacyclovir 1000 mg three times daily for 7 days 1, 3
• Acyclovir 800 mg five times daily for 7 days 1, 3
• Famciclovir 500 mg three times daily for 7 days 1

Valacyclovir is preferred due to superior bioavailability and less frequent dosing, improving adherence 3. The 4-day delay does not preclude benefit—antiviral therapy reduces ocular complications and postherpetic neuralgia even when started beyond 72 hours in HZO 1, 2.

Escalate to IV Therapy If:

Switch to intravenous acyclovir 10 mg/kg every 8 hours for 1:

• Immunocompromised status (HIV, chemotherapy, chronic corticosteroids >10 mg/day prednisone equivalent, transplant recipients)
• Disseminated disease (lesions beyond primary dermatome)
• Failure to improve within 7-10 days on oral therapy
• Severe ocular involvement with vision-threatening complications

Urgent Ophthalmology Referral (Within 24 Hours)

Arrange same-day or next-day ophthalmology evaluation for comprehensive slit-lamp examination to assess 1, 2:

• Corneal involvement (punctate keratitis, pseudodendritic lesions, stromal keratitis)
• Anterior uveitis
• Elevated intraocular pressure
• Acute retinal necrosis (rare but devastating)
• Conjunctival/limbal vesicles

Approximately 50% of HZO patients develop ocular complications requiring specialized management 4. The ophthalmologist will determine need for topical corticosteroids and monitor for sequelae.

Ocular Supportive Care (Start Immediately)

While awaiting ophthalmology consultation 1, 2:

• Non-preserved ocular lubricants (hyaluronate or carmellose drops) every 2 hours throughout acute illness
• Daily ocular hygiene by ophthalmologist or trained nurse once consultation obtained
• Broad-spectrum topical antibiotics (moxifloxacin drops four times daily) if any corneal fluorescein staining or ulceration present

Critical Pitfall to Avoid

Never initiate topical corticosteroids without concurrent systemic antiviral therapy and ophthalmology guidance 1. Corticosteroids potentiate viral replication and can worsen VZV disease if used alone. Only the ophthalmologist should prescribe topical steroids after confirming adequate systemic antiviral coverage.

Pain Management

Elderly patients with HZO often experience severe neuropathic pain 5, 6:

• Acute pain: Consider short-term opioids if severe (tramadol or oxycodone)
• Neuropathic pain adjuncts: Start gabapentin 300 mg at bedtime, titrate to 300-600 mg three times daily, or pregabalin 75 mg twice daily 5
• Tricyclic antidepressants: Amitriptyline 10-25 mg at bedtime (caution in elderly due to anticholinergic effects) 5

Renal Dosing Adjustments

For elderly patients, check creatinine clearance and adjust antiviral dosing accordingly 1, 3:

• CrCl 30-49 mL/min: Valacyclovir 1000 mg twice daily
• CrCl 10-29 mL/min: Valacyclovir 1000 mg once daily
• CrCl <10 mL/min: Valacyclovir 500 mg once daily

Expected Clinical Course and Follow-up

• Daily ophthalmology review during acute illness (first 7-14 days) 2
• Lesions continue erupting for 7-14 days; healing occurs more slowly without adequate antiviral therapy 2
• Monitor for postherpetic neuralgia (PHN), which occurs in approximately 50% of patients aged ≥80 years 6

Long-term Sequelae to Monitor

Potential complications requiring ongoing surveillance 7:

• Stromal keratitis with scarring
• Corneal anesthesia and neurotrophic keratopathy
• Chronic dry eye
• Uveitis with secondary glaucoma or cataract
• Retinitis (rare)
• Postherpetic neuralgia (most common long-term complication)

Prevention of Future Episodes

Once acute symptoms resolve (typically 2 months post-episode), administer Shingrix (recombinant zoster vaccine) as a 2-dose series (doses 2-6 months apart) 1, 8, 2. Having shingles once does not provide reliable protection—the 10-year recurrence risk is 10.3%, and Shingrix provides 97.2% efficacy against future episodes 1, 2.

Why This Aggressive Approach Matters

Without prompt systemic antiviral therapy, HZO carries a 10-20% risk of dissemination (viral pneumonia, encephalitis, hepatitis) and up to 50% risk of ocular complications including vision loss 2, 4. The combination of immediate antivirals, urgent ophthalmology consultation, and intensive supportive care dramatically reduces morbidity and preserves vision 1, 2.