Treatment for Herpes Zoster Ophthalmicus

Systemic Antiviral Therapy

• The American Academy of Ophthalmology recommends initiating oral antiviral therapy immediately, ideally within 72 hours of rash onset, with acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg three times daily for 7 days, or famciclovir 500 mg three times daily for 7 days, combined with urgent ophthalmologic consultation and intensive ocular supportive care 1
• Standard dosing regimens for oral antivirals include acyclovir 800 mg five times daily for 7 days, valacyclovir 1000 mg every 8 hours for 7 days, and famciclovir 500 mg three times daily for 7 days, as recommended by the American Academy of Ophthalmology 1

Management of Specific Ocular Complications

• The American Academy of Ophthalmology suggests that topical corticosteroids may be necessary for stromal keratitis or uveitis, but must be used in conjunction with systemic antiviral therapy to prevent viral replication 1
• The American Academy of Ophthalmology recommends using corticosteroids with poor ocular penetration, such as fluorometholone, rimexolone, or loteprednol, when possible to minimize risk of elevated intraocular pressure and cataract formation 1
• The American Academy of Ophthalmology advises tapering corticosteroids slowly to the minimum effective dose to prevent rebound inflammation 1

Common Pitfalls to Avoid

• The American Academy of Ophthalmology warns against using topical corticosteroids without concurrent systemic antiviral therapy, as steroids potentiate HSV infection and can worsen VZV disease 1
• The American Academy of Ophthalmology recommends avoiding topical trifluridine for more than 2 weeks as it inevitably causes epithelial toxicity 1

Special Population Considerations

• The American Academy of Ophthalmology suggests that prolonged treatment may be necessary for patients with chronic disease, with dose adjustment according to clinical response 1
• The American Academy of Ophthalmology advises exercising caution in patients with impaired renal clearance, adjusting antiviral dosing accordingly 1

Treatment for Herpes Zoster Ophthalmicus

Ocular Management

• Daily ophthalmological review is necessary during the acute illness, and apply non-preserved ocular lubricants (e.g., hyaluronate or carmellose eye drops) every 2 hours throughout the acute illness, according to the British Journal of Dermatology 2
• Ocular hygiene must be performed daily by an ophthalmologist or ophthalmically trained nurse, and consider topical corticosteroid drops (e.g., non-preserved dexamethasone 0.1% twice daily) to reduce ocular surface damage, as recommended by the British Journal of Dermatology 2
• Administer broad-spectrum topical antibiotics (e.g., moxifloxacin drops four times daily) if corneal fluorescein staining or ulceration is present, as suggested by the British Journal of Dermatology 2

Special Considerations

• Immunocompromised patients are at higher risk for disseminated disease and may require more aggressive treatment, possibly including intravenous antivirals, according to Clinical Infectious Diseases 3

Prevention

• The American Academy of Ophthalmology recommends the recombinant zoster vaccine (RZV) for prevention of herpes zoster and related complications in immunocompetent adults aged 50 years or older, immunocompromised patients 19 years and older, and adults who previously received the older zoster vaccine live (ZVL), as stated in Ophthalmology 4
• RZV is preferred over ZVL due to higher efficacy (96% vs. 70%), as reported in Ophthalmology 4

Prevention and Management of Ocular Shingles

Special Considerations

• For unconscious patients, prevention of corneal exposure is essential using polyethylene film to create a moisture chamber 5

Treatment of Herpes Zoster Ophthalmicus with Antiviral Therapy

Patient Management

• Immunocompromised patients, such as those with HIV, chemotherapy, chronic corticosteroids, or transplant recipients, should be switched to intravenous acyclovir 10 mg/kg every 8 hours, as recommended by the Infectious Diseases Society of America 6
• Patients with disseminated disease, lesions beyond the primary dermatome, should receive intravenous acyclovir 10 mg/kg every 8 hours, according to the Clinical Infectious Diseases guidelines 6
• The American Academy of Ophthalmology recommends that patients who fail to improve within 7-10 days despite appropriate therapy should be suspected of having acyclovir resistance, and viral culture with susceptibility testing should be obtained, with a potential switch to foscarnet 40 mg/kg IV every 8 hours 6

Treatment Protocols

• The Centers for Disease Control and Prevention recommends that high-dose IV acyclovir remains the treatment of choice for VZV infections in compromised hosts, as oral therapy should be reserved only for mild cases with transient immunosuppression 6

Herpes Zoster Ophthalmicus Management

Ocular Complications and Treatment

• The American Academy of Ophthalmology recommends arranging same-day or next-day ophthalmology evaluation for comprehensive slit-lamp examination to assess corneal involvement, anterior uveitis, elevated intraocular pressure, and acute retinal necrosis in patients with herpes zoster ophthalmicus 7
• Approximately 50% of HZO patients develop ocular complications, including stromal keratitis with scarring, which requires ongoing surveillance 8

Prevention of Future Episodes

• The Centers for Disease Control and Prevention recommends administering Shingrix (recombinant zoster vaccine) as a 2-dose series, 2-6 months apart, once acute symptoms resolve, to provide 97.2% efficacy against future episodes 7, 8

Management of Acute Shingles and Vaccination Timing

Infection Control Precautions

• Implement standard precautions for all herpes zoster cases, and add airborne and contact precautions if disseminated zoster is present or if the patient is immunocompromised, as recommended by the American Journal of Kidney Diseases guidelines 9, 10
• Antiviral therapy decreases viral shedding and lowers the duration of lesions, according to the American Journal of Kidney Diseases guidelines 9, 10