Treatment of Chronic Conjunctivitis After Herpes Zoster
For chronic conjunctivitis following herpes zoster ophthalmicus, use topical corticosteroids at the minimum effective dose in conjunction with systemic antiviral therapy, with slow tapering to prevent rebound inflammation. 1
Initial Assessment and Diagnosis
The chronic conjunctivitis you're managing is likely part of the spectrum of persistent ocular complications that occur in approximately 50% of herpes zoster ophthalmicus (HZO) patients, with up to 25% developing chronic or recurrent disease. 2 This requires ongoing ophthalmologic surveillance to identify the specific inflammatory pattern—whether stromal keratitis, uveitis, or chronic conjunctival inflammation. 1, 3
Primary Treatment Strategy
Topical Corticosteroid Therapy
- Use corticosteroids with poor ocular penetration such as fluorometholone, rimexolone, or loteprednol to minimize the risk of elevated intraocular pressure and cataract formation. 1
- Taper slowly to the minimum effective dose once inflammation is controlled to prevent rebound inflammation. 1
- Monitor intraocular pressure and lens status regularly during prolonged corticosteroid use through periodic pupillary dilation and IOP measurement. 4
Critical Safety Requirement
Never use topical corticosteroids without concurrent systemic antiviral therapy, as steroids potentiate viral replication and can worsen VZV disease. 1, 3 This is a fundamental principle that distinguishes chronic HZO management from other forms of chronic conjunctivitis.
Concurrent Systemic Antiviral Coverage
When using topical corticosteroids for chronic inflammation, maintain systemic antiviral prophylaxis with:
- Acyclovir 400 mg twice daily, or
- Valacyclovir 500 mg once or twice daily, or
- Famciclovir 250 mg twice daily 4
These lower prophylactic doses prevent viral reactivation while you manage the chronic inflammatory component with topical steroids. 4
Adjunctive Supportive Care
- Apply non-preserved ocular lubricants (hyaluronate or carmellose eye drops) every 2 hours to address surface inflammation and dryness. 1
- Perform daily ocular hygiene to reduce inflammatory debris and improve comfort. 1
- Consider broad-spectrum topical antibiotics (such as moxifloxacin four times daily) if there is corneal fluorescein staining or ulceration suggesting secondary bacterial involvement. 1
Monitoring Schedule
- Regular follow-up visits should include interval history, visual acuity measurement, IOP measurement, and slit-lamp biomicroscopy. 4
- Evaluate for corneal subepithelial infiltrates, which typically occur 1 or more weeks after onset and may persist chronically. 4
- Watch for cicatricial changes such as foreshortening of the conjunctival fornix, which can occur with severe chronic disease. 4
When Treatment Fails
If the patient fails to improve within 7-10 days despite appropriate therapy:
- Suspect acyclovir resistance and obtain viral culture with susceptibility testing. 1
- Consider switching to foscarnet 40 mg/kg IV every 8 hours for resistant cases. 1
Common Pitfalls to Avoid
- Avoid topical trifluridine for more than 2 weeks as it inevitably causes epithelial toxicity. 1
- Do not use topical antivirals alone for VZV conjunctivitis, as they have not been shown to be helpful. 4
- Never stop corticosteroids abruptly in chronic cases, as this causes rebound inflammation. 1
Special Considerations for Older Adults
Older adults with chronic HZO conjunctivitis require:
- Dose adjustment for renal impairment when using systemic antivirals. 1, 3
- More aggressive monitoring for corticosteroid complications (glaucoma, cataracts) given age-related susceptibility. 4
- Prolonged treatment duration based on clinical response rather than arbitrary time limits. 1
Prevention of Future Episodes
Strongly recommend the recombinant zoster vaccine (Shingrix) once acute symptoms resolve, administered as a 2-dose series 2-6 months apart, which provides 97.2% efficacy against future episodes. 1 This is preferred over the older live vaccine due to 96% efficacy versus 70%. 1, 3