Herpes Zoster Ophthalmicus (HZO) - Treatment

Herpes zoster keratitis with pseudodendrites (Wills Eye Manual)

1. Systemic Antiviral Therapy

• Severity and duration of the acute episode
• Risk of post-herpetic neuralgia
• Incidence of late ophthalmic complications by ~50%

• Immunocompromised patients (moderate-severe)
• Orbital involvement
• Optic nerve or cranial nerve involvement
• CNS involvement (encephalitis)
• Severely ill patients

2. Systemic Corticosteroids

• Prednisolone 60 mg/day for 4 days → 40 mg for 4 days → 20 mg for 4 days (tapering course)
• Reduces acute pain and accelerates skin healing
• Does NOT reduce the incidence or severity of post-herpetic neuralgia
• Contraindicated in immunocompromised patients

3. Skin Lesion Care

• Ophthalmic antibiotic ointment (bacitracin or erythromycin) to skin lesions b.i.d.
• Warm compresses to periocular skin three times daily
• Drying, antisepsis, and cold compresses for symptomatic relief

4. Ocular Complications - Specific Treatment

Conjunctivitis

• Cool compresses + ophthalmic antibiotic ointment (bacitracin/erythromycin) b.i.d.
• No specific treatment needed in absence of corneal disease

Superficial Punctate Keratitis (SPK)

• Preservative-free artificial tears q1-2h + lubricating ointment at bedtime

Pseudodendrites / Corneal Mucous Plaques

• Preservative-free tears q1-2h + ointment at bedtime
• Antibiotic ointment to prevent bacterial superinfection
• Topical ganciclovir gel 4-5x daily for recalcitrant lesions

Immune Stromal Keratitis

• Topical steroid (prednisolone acetate 1%) 4-8x per day, adjusted by response
• Taper over months to years to less than daily dosing - relapses are common

Nummular Keratitis

• Develops ~10 days after rash onset at the site of prior epithelial lesions
• Treat with topical steroids if symptomatic (similar regimen to stromal keratitis)

Episcleritis

• Usually resolves spontaneously
• Mild NSAID (e.g., flurbiprofen 100 mg three times daily) if needed

Scleritis / Sclerokeratitis

• Oral flurbiprofen 100 mg three times daily for mild-moderate disease
• Oral steroids with antiviral cover for severe disease

Uveitis (Anterior)

• Topical steroid (prednisolone acetate 1%) 4-8x daily
• Cycloplegic drop (cyclopentolate 1% three times daily)
• Aggressive aqueous suppression for elevated IOP
• Avoid prostaglandin analogues

Neurotrophic Keratitis

• Mild: ophthalmic antibiotic ointment (erythromycin) and lubrication
• Moderate-severe: consider bandage contact lens, tarsorrhaphy, or amniotic membrane transplant
• Refer to corneal specialist

Elevated IOP (secondary to inflammation or steroids)

• Aqueous suppressants: timolol 0.5% daily/b.i.d., brimonidine 0.2% t.i.d., or dorzolamide 2% t.i.d.
• Oral carbonic anhydrase inhibitors if IOP >30 mmHg
• If steroid-induced with controlled inflammation: switch to fluorometholone 0.1% or loteprednol 0.5% and taper
• Avoid prostaglandin analogues in uveitis setting

Retinitis / Choroiditis / Optic Neuritis / Cranial Nerve Palsy

• IV acyclovir 10 mg/kg q8h x 1 week + prednisone 60 mg p.o. x 3 days, then taper over 1 week
• Acute Retinal Necrosis (ARN) or Progressive Outer Retinal Necrosis (PORN): may require intraocular antivirals
• Infectious disease + neurology consultation to rule out CNS involvement
• Note: severe disease can cause large-vessel cranial arteritis leading to CVA

5. Pain Management

• Acute pain (first 2 weeks) may require narcotic analgesics
• Gabapentin or pregabalin - useful for both acute pain and post-herpetic neuralgia
• Amitriptyline 25 mg t.i.d. - benefits both post-herpetic neuralgia and associated depression
• Topical capsaicin 0.025% or doxepin ointment applied to skin (not near eyes) t.i.d.-q.i.d. after rash heals
• Pain management specialist referral for persistent post-herpetic neuralgia

6. Children

• Acyclovir 20 mg/kg q8h (weight-based) for children <12 years or <40 kg
• Adult dosing for older/heavier children
• Co-manage with pediatrics and infectious disease for systemic spread

7. Prevention (Vaccination)

• Zoster vaccine live (Zostavax) - attenuated live virus; efficacy decreases within 10 years
• Recombinant zoster vaccine (Shingrix) - requires 2 injections; ~10% local/systemic reactions; preferred for better durability

Follow-Up

• With ocular involvement: every 1-7 days depending on severity
• Without ocular involvement: every 1-4 weeks
• After acute resolution: every 3-6 months (every 3 months if on steroids) - relapses may occur months to years later, especially during steroid taper

Infection control: VZV is contagious to varicella-naive individuals (especially pregnant women) until all lesions have crusted.