Treatment of Herpes Zoster Ophthalmicus (Shingles Involving the Eye)
Initiate oral valacyclovir 1000 mg three times daily for 7 days immediately, arrange urgent same-day or next-day ophthalmology consultation, and begin intensive ocular supportive care. 1
Immediate Systemic Antiviral Therapy
The cornerstone of treatment is starting oral antiviral therapy within 72 hours of rash onset, though earlier initiation (within 48 hours) provides optimal efficacy. 1, 2 The American Academy of Ophthalmology recommends three equivalent first-line options:
- Valacyclovir 1000 mg three times daily for 7 days (preferred due to superior bioavailability and less frequent dosing) 1, 3
- Acyclovir 800 mg five times daily for 7 days 1, 3
- Famciclovir 500 mg three times daily for 7 days 1
Critical treatment endpoint: Continue antiviral therapy until all lesions have completely scabbed, not just for an arbitrary 7-day period—if lesions are still forming or haven't scabbed at day 7, extend treatment. 1, 4
Urgent Ophthalmology Referral
Arrange same-day or next-day comprehensive slit-lamp examination to assess for corneal involvement, anterior uveitis, elevated intraocular pressure, and acute retinal necrosis. 1 Approximately 50% of herpes zoster ophthalmicus patients develop ocular complications including stromal keratitis with scarring, requiring ongoing surveillance. 1
Intensive Ocular Supportive Care
Daily Ocular Management
- Apply non-preserved ocular lubricants (hyaluronate or carmellose eye drops) every 2 hours throughout the acute illness 1
- Daily ophthalmological review during acute illness with ocular hygiene performed by an ophthalmologist or ophthalmically trained nurse 1
- Consider topical corticosteroid drops (non-preserved dexamethasone 0.1% twice daily) to reduce ocular surface damage 1
- Administer broad-spectrum topical antibiotics (moxifloxacin drops four times daily) if corneal fluorescein staining or ulceration is present 1
Critical Warning About Corticosteroids
Never use topical corticosteroids without concurrent systemic antiviral therapy—steroids potentiate HSV infection and can worsen VZV disease. 1 When corticosteroids are necessary for stromal keratitis or uveitis, use agents with poor ocular penetration (fluorometholone, rimexolone, or loteprednol) to minimize risk of elevated intraocular pressure and cataract formation. 1 Taper slowly to the minimum effective dose to prevent rebound inflammation. 1
When to Escalate to Intravenous Therapy
Switch to intravenous acyclovir 10 mg/kg every 8 hours if any of the following occur: 1, 4
- Immunocompromised status (HIV, chemotherapy, chronic corticosteroids, transplant recipients)
- Disseminated disease (lesions beyond the primary dermatome)
- Failure to improve within 7-10 days despite appropriate oral therapy
- Suspected acyclovir resistance (obtain viral culture with susceptibility testing and consider foscarnet 40 mg/kg IV every 8 hours) 1
Renal Dosing Adjustments
Exercise caution in patients with impaired renal clearance—adjust antiviral dosing according to creatinine clearance to prevent acute renal failure. 1, 3 Monitor renal function at initiation and once or twice weekly during treatment. 4
Prevention of Future Episodes
Administer Shingrix (recombinant zoster vaccine) as a 2-dose series, 2-6 months apart, once acute symptoms resolve—this provides 97.2% efficacy against future episodes and is recommended for all immunocompetent adults aged 50 years or older. 1 This vaccine is strongly preferred over the older live vaccine due to 96% versus 70% efficacy. 1
Common Pitfalls to Avoid
- Do not use topical trifluridine for more than 2 weeks—it inevitably causes epithelial toxicity 1
- Do not delay treatment waiting for ophthalmology consultation—start oral antivirals immediately while arranging urgent referral 1
- Do not stop antivirals at exactly 7 days if lesions haven't fully scabbed—the clinical endpoint is complete crusting, not calendar days 1, 4
- Do not use topical antivirals alone—they are substantially less effective than systemic therapy 4