HERPES ZOSTER OPHTHALMICUS Treatment

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Therapeutic approach to herpes zoster ophthalmicus should be vigorous and aimed at preventing severe devastating ocular complications and promoting rapid healing of the skin lesions without the formation of massive crusts which result in scarring of the nerves and postherpetic
neuralgia. The following regime may be followed:

I. Systemic therapy for herpes zoster
1. Oral antiviral drugs. These significantly decrease pain, curtail vesiculation, stop viral progression and reduce the incidence as well as severity of keratitis and iritis. In order to be effective, the treatment should be started immediately after the onset of rash. It has no effect on post herpetic neuralgia.

• Acyclovir in a dose of 800 mg 5 times a day for 10 days, or  
•  Valaciclovir in a dose of 500mg TDS

2. Analgesics. Pain during the first 2 weeks of an attack is very severe and should be treated by analgesics such as combination of mephenamic acid and paracetamol or pentazocin or even pethidine (when very severe).

3. Systemic steroids. They appear to inhibit development of post-herpetic neuralgia whengiven in high doses. However, the risk of high doses of steroids in elderly should always be taken into consideration. Steroids are commonly
recommended in cases developing neurological complications such as third nerve palsy and optic neuritis.

4. Cimetidine in a dose of 300 mg QID for 2-3 weeks starting within 48-72 hours of onset has also been shown to reduce pain and pruritis in acute
zoster - presumably by histamine blockade.

5. Amitriptyline should be used to relieve the accompanying depression in acute phase.

II. Local therapy for skin lesions
1. Antibiotic-corticosteroid skin ointment or lotions. These should be used three times a day till skin lesions heal.
2. No calamine lotion. Cool zinc calamine application, as advocated earlier, is better avoided, as it promotes crust formation.

III. Local therapy for ocular lesions
1. For zoster keratitis, iridocyctitis and scleritis
i. Topical steroid eye drops 4 times a day.
ii. Cycloplegics such as cyclopentolate eyedrops BD or atropine eye ointment OD.
iii. Topical acyclovir 3 percent eye ointment should be instilled 5 times a day for about 2 weeks.
2. To prevent secondary infections topical antibiotics are used.
3. For secondary glaucoma
i. 0.5 percent timolol or 0.5% betaxolol drops BD.
ii. Acetazolamide 250 mg QID.
4. For neuroparalytic corneal ulcer caused by herpes zoster, lateral tarsorrhaphy should be performed.
5. For persistent epithelial defects use :
i. Lubricating artificial tear drops, and
ii. Bandage soft contact lens.
6. Keratoplasty. It may be required for visual rehabilitation of zoster-patients with dense scarring. However, these are poor risk patients.