Evidence‑Based Management of Herpes Zoster Ophthalmicus

Immediate Antiviral Treatment

Initiate systemic antiviral therapy within 72 hours of rash onset to lower the risk of ocular complications, severe pain, and post‑herpetic neuralgia. Strong recommendation (Level A). – American Academy of Ophthalmology 1
First‑line oral regimens (all 7‑day courses) are equivalent:
Strong recommendation (Level A). – American Academy of Ophthalmology 1
Valacyclovir and famciclovir provide simpler dosing and are more cost‑effective than acyclovir while maintaining comparable efficacy. Strong recommendation (Level A). – American Academy of Ophthalmology 1

Apply prophylactic topical antibiotics to prevent secondary bacterial infection that can cause conjunctival scarring and cicatricial ectropion. Strong recommendation (Level A). – American Academy of Ophthalmology 4
Topical antivirals alone are ineffective for VZV conjunctivitis; they may be added only as adjunctive therapy in refractory cases. Conditional recommendation (Level B). – American Academy of Ophthalmology 4

Obtain urgent ophthalmology consultation for every HZO case because approximately 50 % develop ocular complications (keratitis, corneal scarring, uveitis, sectoral iris atrophy, secondary glaucoma). Strong recommendation (Level A). – American Academy of Ophthalmology 1
Perform daily ophthalmologic review throughout the acute phase. Strong recommendation (Level A). – British Association of Dermatologists 5
Use non‑preserved ocular lubricants (e.g., hyaluronate or carmellose drops) every 2 hours during the acute period to maintain surface moisture. Strong recommendation (Level A). – British Association of Dermatologists 5

Immunocompromised patients require more aggressive management, including possible dose escalation and extended therapy duration. Strong recommendation (Level A). – American Academy of Ophthalmology 1
For severe disease with neurological involvement or retinal infection, consider intravenous acyclovir. Strong recommendation (Level A). – CDC (MMWR) 6
Adjust systemic antiviral dosing in patients with estimated GFR < 45 mL/min/1.73 m² to avoid toxicity. Strong recommendation (Level A). – American Academy of Ophthalmology 1

In stromal keratitis or uveitis, initiate topical corticosteroids at the minimum effective dose after epithelial healing, always with concurrent systemic antiviral coverage. Strong recommendation (Level A). – American Academy of Ophthalmology 7
Prefer corticosteroids with poor intra‑ocular penetration (e.g., fluorometholone, loteprednol) to reduce the risk of intra‑ocular pressure rise and cataract formation. Conditional recommendation (Level B). – American Academy of Ophthalmology 8
Monitor for late sequelae such as dry eye, corneal anesthesia with neurotrophic keratitis, and post‑herpetic neuralgia; chronic or recurrent disease may necessitate prolonged therapy or prophylaxis. Strong recommendation (Level A). – American Academy of Ophthalmology 1

Schedule a follow‑up visit within 1 week of presentation, including interval history, visual acuity, intra‑ocular pressure measurement, and slit‑lamp biomicroscopy. Strong recommendation (Level A). – American Academy of Ophthalmology 8
Continue surveillance for sub‑epithelial infiltrates, which typically appear ≥1 week after onset of conjunctivitis. Conditional recommendation (Level B). – American Academy of Ophthalmology 8

Recommend recombinant zoster vaccine (RZV) for all adults ≥ 50 years; RZV provides ≈ 96 % efficacy versus ≈ 70 % for the live‑attenuated vaccine. Strong recommendation (Level A). – American Academy of Ophthalmology 9
RZV is preferred and safe for immunocompromised individuals, whereas the live‑attenuated vaccine is contraindicated. Strong recommendation (Level A). – CDC (Journal of Microbiology, Immunology and Infection) 10

Avoid topical corticosteroids without concurrent systemic antiviral therapy; steroids can enhance viral replication and worsen epithelial disease. Strong recommendation (Level A). – American Academy of Ophthalmology 7