A New Standard in Managing HZO

Each year, approximately one million individuals in the United States are diagnosed with herpes zoster (shingles),^1,2 a condition caused by the reactivation of the varicella-zoster virus. Of particular concern to eye care providers is herpes zoster ophthalmicus (HZO), which occurs when the virus involves the ophthalmic branch of the trigeminal nerve. HZO presents with unilateral pain, rash, and vesicular lesions along the affected dermatome, often involving the forehead, periocular region, and cornea (Figure). Complications such as postherpetic neuralgia, keratitis, iritis, and other forms of ocular inflammation can result in long-term morbidity, vision loss, and reduced quality of life. Thus, prompt treatment and close monitoring are key to preventing any unwanted issues.

MANAGING SHINGLES AND HZO

Traditionally, shingles is treated with a 7- to 10-day course of oral antivirals. However, new research from the Zoster Eye Disease Study (ZEDS) has demonstrated the benefit of extended antiviral prophylaxis for reducing ocular complications and pain in patients with HZO.³ Led by Elisabeth J. Cohen, MD, a cornea surgeon and professor at New York University Grossman School of Medicine, ZEDS is a pivotal, multicenter, randomized clinical trial investigating the long-term effects of low-dose antiviral therapy in HZO.

The trial enrolled 527 immunocompetent patients with HZO who were randomized into two groups: The first group received 1,000 mg of valacyclovir daily for 12 months, and the second received a placebo.³ The study found the following:

Reduced Ocular Recurrence. Patients treated with valacyclovir had significantly fewer episodes of keratitis and iritis compared with the placebo group at both 12 and 18 months,³ suggesting prolonged antiviral therapy may help prevent recurrent inflammation and ocular damage.

Improved Pain Management. Valacyclovir reduced the severity and duration of postherpetic neuralgia, decreasing the need for additional neuropathic pain medications.³

Visual Preservation. By reducing flare-ups, prolonged treatment with antivirals mitigated the risk of vision loss associated with corneal involvement.³

These findings underscore the importance of extending antiviral therapy in patients with HZO to improve visual and systemic outcomes.

PREVENTING HERPES ZOSTER

Prevention remains key in managing herpes zoster. The CDC recommends the Zoster vaccine recombinant, adjuvanted (Shingrix, GSK) vaccine for:⁴

• Adults 50 years of age and older
• Immunocompromised adults 19 years of age and older

Vaccination lowers the risk of developing shingles and HZO and reduces the severity of associated complications. Individuals with a history of shingles remain at risk for recurrence and should be vaccinated once the acute episode has resolved.

CLINICAL IMPLICATIONS

Optometrists are often the first to recognize and manage HZO. By incorporating these new insights from ZEDS, we can play a vital role in reducing the burden of HZO and preserving patients’ vision and quality of life.