Tips for Managing Herpes Zoster Ophthalmicus

The cornea may be affected in up to half of all patients who have herpes zoster ophthalmicus (HZO). The most common manifestation is a self-limited punctate epithelial keratitis that develops within the first two weeks after the onset of the HZO rash.

“A significant percentage of patients develop more serious long-term complications, including keratitis, uveitis and eyelid scarring that can lead to long-term vision impairment,” says Jeffrey Goshe, MD.

Acute treatment

Start patients on oral antiviral medication (acyclovir, valacyclovir or famciclovir) within 72 hours of the onset of symptoms to reduce the risk of long-term sequelae, including postherpetic neuralgia. Typically, a 10- to 14-day course of one of these medications is sufficient, Dr. Goshe says.

Long-term management of complications

1. Postherpetic neuralgia: Collaborate with a neurologist or neuro-ophthalmologist. Gabapentin and amitriptyline, often used in combination, are the most effective medications. These can be titrated as needed. However, patients often experience drowsiness and dryness in the eyes and/or mouth.

2. Milder chronic corneal complications include dry-eye syndrome and meibomian gland dysfunction. Oral doxycycline or topical azithromycin eye drops can help with more severe cases. Treat pseudodendrites with topical steroids and a broad-spectrum topical antibiotic. Gentle debridement at the slit lamp can also be performed.

3. Chronic corneal inflammation, including nummular and interstitial keratitis: Aggressively administer topical steroids to reduce the threat of corneal scarring. When the eye is quiet, slowly taper the dose over weeks or months. In case of recurrence, increase the steroids and lengthen the taper. Daily or every-other-day dosing for months or years is not uncommon. Use a low potency steroid (e.g., fluorometholone 0.1 percent) as a long-term agent to minimize the risk of elevated IOP.

4. Corneal scarring may require corneal transplantation. Less aggressive measures include rigid gas permeable or scleral contact lenses. Approach corneal transplantation with extreme caution; delayed epithelialization (which may result in severe corneal melting), graft rejection and chronic ocular surface disease can occur. Application of a sutured amniotic membrane with temporary or permanent tarsorrhaphy at the time of keratoplasty may avoid some early complications from delayed wound healing. Closely monitor patients indefinitely.

5. Severe neurotrophic keratopathy and chronic non-healing epithelial defects: Use a stepwise approach — from preservative-free artificial tears to punctal plugs or cautery. A temporary bandage contact lens can speed epithelialization if trichiasis is a factor. Mucus membrane grafting by an oculoplastics specialist may be needed to prevent recurrent scarring.
5a. Severe cases with limbal stem cell deficiency: Add a compounded 5 percent albumin solution four to eight times daily or autologous serum drops (typically with 50 percent dilution) every one to two hours while awake. A conservative permanent lateral tarsorrhaphy of 10-20 percent can provide long-term protection. Maintain a low threshold for this intervention in patients with recurrent corneal epithelial breakdown who are on aggressive topical lubrication.

Antiviral medications

Consider long-term oral prophylaxis in patients with recurrent epithelial lesions (pseudodendrites or punctate epithelial keratitis) or any type of chronic stromal keratitis uveitis. Acyclovir 800 mg BID, valacyclovir 1 g QD, and famciclovir 500 mg QD are acceptable. “I typically use acyclovir as first line treatment because of the low cost, but some patients respond better to famciclovir,” Dr. Goshe says.

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