What is the treatment for Herpes Zoster Ophthalmicus (HZO), also known as shingles affecting the eye?

From the Guidelines

Treatment for herpes zoster ophthalmicus (HZO) should be initiated as soon as possible, ideally within 72 hours of rash onset, with oral antiviral medications such as valacyclovir 1000 mg every 8 hours for 7 days, as recommended by the most recent and highest quality study 1.

Key Considerations

• The goal of treatment is to reduce the risk of complications like postherpetic neuralgia, corneal scarring, and vision loss.
• Antiviral medications should be started promptly, ideally within 72 hours of rash onset.
• The recommended regimen is oral valacyclovir 1000 mg every 8 hours for 7 days, or alternatively, oral acyclovir 800 mg five times daily or famciclovir 500 mg three times daily for 7 days.
• For severe cases or immunocompromised patients, intravenous acyclovir 10 mg/kg every 8 hours may be necessary.
• Pain management is essential and may include acetaminophen, NSAIDs, or in severe cases, opioids or gabapentin.
• Topical lubricating eye drops should be used to prevent corneal drying.
• If ocular involvement is present, topical steroids such as prednisolone acetate 1% may be prescribed under ophthalmological supervision to reduce inflammation.

Important Notes

• Patients should be advised to keep the rash clean and avoid touching or scratching to prevent secondary bacterial infection.
• Prompt treatment reduces the risk of complications and improves outcomes.
• The varicella-zoster virus reactivates in the ophthalmic branch of the trigeminal nerve, making early intervention crucial to prevent permanent damage to ocular structures.
• The most recent and highest quality study 1 provides the best evidence for guiding treatment decisions in HZO.

From the Research

Treatment Options for Herpes Zoster Ophthalmicus

• The treatment of herpes zoster ophthalmicus typically involves the use of systemic antiviral medications, such as valacyclovir and acyclovir, to manage the infection and prevent complications 2, 3, 4, 5.
• Valacyclovir has been shown to be at least as effective as acyclovir in preventing ocular complications of herpes zoster ophthalmicus, including conjunctivitis, superficial and stromal keratitis, and pain 3, 4.
• A systematic review of high-quality randomized controlled trials found that valacyclovir and famciclovir were superior to acyclovir in reducing the risk of herpes-zoster-associated pain, with valacyclovir showing a significant reduction in pain up to 112 days 5.
• The European guidelines on the management of herpes zoster recommend systemic antiviral treatment and adequate pain medication as the mainstay of treatment for herpes zoster ophthalmicus, particularly in immunocompromised and/or elderly patients 6.

Comparison of Valacyclovir and Acyclovir

• A study comparing the efficacy and safety of valacyclovir and acyclovir for the treatment of herpes zoster ophthalmicus found that valacyclovir was as effective as acyclovir in preventing ocular complications, with similar tolerance and adverse event profiles 3.
• Another study found that valacyclovir alleviated zoster-associated pain and postherpetic neuralgia significantly faster than acyclovir, with a 14-day regimen showing no significant advantage over a 7-day regimen 4.
• A systematic review found that valacyclovir and famciclovir were preferred treatment options for herpes zoster, including ophthalmicus, due to their significant reduction in risk of herpes-zoster-associated pain and more convenient dosing regimens 5.

Management and Prevention of Complications

• Herpes zoster ophthalmicus can lead to complications such as conjunctivitis, superficial and stromal keratitis, anterior uveitis, and acute retinal necrosis, particularly in immunocompromised and/or elderly patients 6.
• Systemic antiviral treatment and adequate pain medication are essential in preventing and managing these complications, and reducing the risk of long-term sequelae such as postherpetic neuralgia 2, 3, 4, 5, 6.