Herpes Simplex Virus and Varicella Zoster Virus Ocular Infections

Introduction to Treatment

The American Academy of Ophthalmology recommends valacyclovir administration at 500 mg two or three times daily for 7 days for herpes simplex virus (HSV) conjunctivitis or keratitis 1
Standard treatment options include oral valacyclovir at 500 mg 2-3 times daily for 7 days, and topical options such as ganciclovir 0.15% gel 3-5 times daily and trifluridine 1% solution 5-8 times daily 1
Oral valacyclovir 1000 mg three times daily for 7 days is a recommended treatment option, offering a simpler dosing schedule with similar efficacy to acyclovir and better bioavailability (3-5 times higher than acyclovir) 1

For persistent or recalcitrant disease, valacyclovir can be administered at 1000 mg every 8 hours for 7 days 1, 2
Patients with chronic disease may require prolonged treatment with dose adjustment based on clinical response 1, 2
Higher doses of oral antivirals may be effective in cases demonstrating resistance to therapy 1
Immunocompromised patients may require more aggressive treatment with higher doses or longer duration of oral antivirals 1, 2

Avoid topical corticosteroids in active epithelial HSV infections as they potentiate viral replication 1
Do not use topical trifluridine beyond 2 weeks due to inevitable epithelial toxicity 1
Do not rely solely on oral antivirals for HSV blepharoconjunctivitis - addition of topical antiviral treatment is more effective 1
Topical corticosteroids should be avoided during acute epithelial disease as they may potentiate viral infection 1, 2

Follow-up examination should be done within 1 week of treatment initiation, including interval history, visual acuity measurement, slit-lamp biomicroscopy, and IOP measurement 1
Lower doses of oral antivirals may be considered for long-term prophylaxis against recurrent HSV conjunctivitis and keratitis 1
Patients with chronic sequelae may require prolonged treatment and/or long-term prophylaxis 1, 2
Regular follow-up should include interval history, visual acuity measurement, and slit-lamp biomicroscopy, with monitoring for late sequelae such as dry eye, corneal anesthesia with neurotrophic keratitis, and post-herpetic neuralgia 1, 2

Mandatory ophthalmology consultation is strongly recommended for management of varicella zoster virus eye infections, with involvement of an experienced ophthalmologist, to assess the extent of ocular involvement and monitor for complications, including conjunctivitis, keratitis, uveitis, and secondary glaucoma 1, 3
The American Academy of Ophthalmology recommends topical antibiotics to prevent secondary bacterial infection of vesicular lesions in patients with herpes zoster ophthalmicus, with immunocompromised patients potentially requiring more aggressive treatment with higher doses or longer duration of oral antivirals 1
Severe cases, including immunocompromised patients, may require intravenous acyclovir 10 mg/kg body weight every 8 hours for 10-14 days, followed by oral valacyclovir 1 g three times daily for 4-6 weeks, as per the MMWR Recommendations and Reports and the Centers for Disease Control and Prevention (CDC) 3
Alternative intravenous acyclovir dosing options include:

Alternative oral antiviral dosing options include:
Topical antivirals alone are not effective for treating VZV conjunctivitis but may be used as adjunctive therapy in unresponsive cases, according to the American Academy of Ophthalmology 1, 2
Patients with renal impairment require dose adjustment for antiviral medications 2