MANAGEMENT OF OPHTHALMIC ZOSTER

The natural history of herpes zoster ophthalmicus and aspects of its t reatment and prevention are presented. Intraocular complications occur in 50 percent of cases. Anterior uveitis and the various varieties of keratitis are commonest, affecting 92% and 52% of patients with ocula r involvement, respectively. Sight-threatening complications include n europathic keratitis, perforation, secondary glaucoma, posterior scler itis/orbital apex syndrome, optic neuritis, and acute retinal necrosis . Twenty-eight percent of initially involved eyes develop long-term oc ular disease (6 months), with chronic uveitis, keratitis, and neuropat hic ulceration being the commonest. Acute pain occurs in 93% of patien ts and is still present in 31% at 6 months. Of patients aged 60 and ov er pain persists in 30% for 6 months or longer, and this rises to 71 % in those aged 80 and over. Current evidence favours the use of topica l acyclovir alone for treatment of established ocular complications, w ith topical steroids being withheld in all but the most severe cases. Stellate ganglion block has proved useful in the treatment of establis hed acute pain. Amitryptiline, and to a lesser extent sodium valproate , are useful in established chronic pain. Evidence of the efficacy of early oral acyclovir on ocular complications is conflicting, with two studies reporting significant improvement in differing disease paramet ers. A similar situation exists for pain, with published studies showi ng differing effects on pain at varying times after the onset of disea se. The use of systemic steroids to prevent pain is not supported by c urrently available evidence, but its therapeutic relationship with acy clovir requires further evaluation. Although limited by poor systemic absorption, oral acyclovir appears to have a beneficial effect on herp es zoster ophthalmicus, and until alternative formulations or better d rugs are developed its use in all cases is justified. (C) 1993 Wiley-L iss, Inc.