Herpes Zoster Ophthalmicus
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Adults 2019 Edition
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B02.3,G53.0
DESCRIPTION
- Herpes zoster ophthalmicus (HZO) occurs when the varicella-zoster virus reactivates in the trigeminal ganglion and passes down the ophthalmic division of the trigeminal nerve.
- Patients present with a painful vesicular rash in the trigeminal V1 area – vesicles on the tip of the nose indicate nasociliary branch involvement, which indicates the risk of ocular involvement.
- A minority of patients may develop conjunctivitis, keratitis, uveitis, retinitis, and cranial nerve involvement (oculomotor or optic nerves).
- Permanent sequelae of ophthalmic zoster infection may include chronic ocular inflammation, loss of vision, and debilitating post-herpetic neuralgia. All patients should be offered HIV testing.
MEDICINE TREATMENT
- Acyclovir, oral, 800 mg 5 doses per day (4 hourly while awake) for 7–10 days.
- Treatment should be initiated within the first three days of onset of symptoms, except in HIV-infected patients who should be treated if there are active skin lesions.
LoE:IVb
For patients unable to take oral medication, severely immunocompromised patients and for patients with complicated HZO e.g. acute retinal necrosis (ARN), optic neuropathy or orbitopathy:
- Acyclovir, IV infusion over one hour, 10 mg/kg 8 hourly for 7-14 days.
- Seek specialist advice for duration of treatment and for switching to oral acyclovir therapy.
- Adjust dose based on renal clearance (See Appendix II for guidance on prescribing and monitoring).
LoE:IIIbxii
Post-herpetic neuralgia
- Initiate treatment with adjuvant therapy (i.e. amitriptyline) early.
- See Management of neuropathic pain (Post-herpetic neuralgia).
LoE:IIIbxiii
REFERRAL
- Vesicles on the tip of the nose.
- Fluorescein staining of cornea shows corneal/ulceration.
- Decreased vision.
- Red eye (uveitis or keratitis).
- Cranial nerve palsies.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.0_30 September 2024
Chapter 18 Eye Disorders_18.4 Herpes Zoster Ophthalmicus