What is the recommended treatment for herpes zoster ophthalmicus?

Treatment of Herpes Zoster Ophthalmicus

Initiate oral valacyclovir 1000 mg three times daily for 7 days immediately upon diagnosis, ideally within 72 hours of rash onset, as this is the preferred first-line antiviral therapy for immunocompetent adults with herpes zoster ophthalmicus. 1, 2

Antiviral Therapy Selection and Timing

First-line treatment options for immunocompetent adults:

• Valacyclovir 1000 mg three times daily for 7 days (preferred due to simpler dosing schedule) 1, 2, 3
• Acyclovir 800 mg five times daily for 7 days (alternative with equivalent efficacy but more frequent dosing) 1, 4
• Famciclovir 500 mg three times daily for 7 days (alternative with similar efficacy to valacyclovir) 1, 5

Critical timing considerations:

• Treatment should be started within 72 hours of rash onset for maximum effectiveness in preventing ocular complications and reducing postherpetic neuralgia 1, 2, 6
• Evidence suggests valacyclovir may still provide benefit when started after 72 hours, so do not withhold treatment in late presenters 7
• A 7-day course is sufficient; extending to 14 days provides no additional benefit 1, 4

For complicated cases or immunocompromised patients:

• Intravenous acyclovir is required for complicated herpes zoster ophthalmicus 1
• Immunocompromised patients (including HIV-infected individuals) need more aggressive therapy with potential dose adjustments and consideration of IV therapy 1, 2
• For HIV-infected patients with recurrent orolabial or genital herpes, use 500 mg twice daily for 7 days 5

Adjunctive Topical Management

Topical antibiotics:

• Apply topical antibiotics to vesicular lesions to prevent secondary bacterial infection and severe conjunctival scarring 8, 1, 2
• This is particularly important as secondary bacterial infection can lead to cicatricial ectropion 8

Topical antivirals:

• Do not use topical antivirals alone as monotherapy - they are ineffective for varicella zoster virus conjunctivitis 8, 1, 2
• May be used as additive treatment in unresponsive patients only when combined with systemic therapy 8

Corticosteroid Management - Critical Safety Considerations

Absolute contraindications:

• Never use topical corticosteroids during active epithelial viral infection - they potentiate viral replication and worsen the infection 8, 1, 2

When corticosteroids may be considered:

• Only after epithelial disease has resolved, for inflammatory complications such as stromal keratitis or uveitis 8, 1, 2
• Must be under direct ophthalmologist supervision with regular monitoring 1, 2
• Use minimum effective dose and taper slowly 8
• Consider corticosteroids with poor ocular penetration (fluorometholone or loteprednol) to minimize risk of elevated intraocular pressure and cataract formation 8

Follow-Up Protocol

Initial follow-up (within 1 week of treatment initiation):

• Interval history focusing on pain, vision changes, and new symptoms 8, 1, 2
• Visual acuity measurement 8, 1, 2
• Slit-lamp biomicroscopy to assess for ocular complications 8, 1, 2
• Intraocular pressure measurement 2

Ongoing monitoring for patients on corticosteroids:

• Regular IOP measurements to detect steroid-induced glaucoma 8, 2
• Pupillary dilation to evaluate for cataract formation 2
• Assess for recurrence of subepithelial infiltrates, which typically occur 1 or more weeks after onset 8

Common ocular complications to monitor:

• Conjunctivitis (occurs in approximately 50% of cases) 3
• Superficial keratitis including punctate keratitis (40-48%) and dendritic keratitis (11%) 3
• Stromal keratitis (13%) 3
• Uveitis (13-17%) 3
• Sectoral iris atrophy, secondary glaucoma, corneal scarring 8

Special Considerations for Immunosuppressed Patients

Management of immunosuppressive therapy:

• In severe cases of disseminated VZV, discontinue immunosuppressive therapy 1
• May restart immunosuppression after commencing anti-VZV therapy and after skin vesicles have resolved 1

Common Pitfalls to Avoid

• Do not delay treatment waiting for laboratory confirmation - initiate therapy based on clinical diagnosis 6
• Do not use topical corticosteroids during active infection, even if inflammation appears severe 8, 1, 2
• Do not rely on topical antivirals alone - systemic therapy is essential 8, 1, 2
• Do not extend treatment beyond 7 days in uncomplicated cases - no additional benefit is gained 1, 4
• Do not forget to adjust dosing in patients with renal impairment 5