Eyeworld

94 | EYEWORLD | MARCH 2021 C ORNEA References 1. Whitley RJ, et al. Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-con- trolled trial. Ann Intern Med. 1996;125:376–383. 2. Wood MJ, et al. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med. 1994;330:896–900. Dr. Cohen also mentioned the Zoster Eye Disease Study (ZEDS), a large NIH/NEI-sup- ported randomized clinical trial she leads that is evaluating whether prolonged low-dose anti- viral treatment reduces chronic and recurrent eye disease and/or post-herpetic neuralgia and should be the new standard of care. She said there is not currently good quality data on this subject. In contrast, antiviral treatment is known to be safe, effective, and the standard of care for herpes simplex eye disease, caused by a related but different herpes virus. "Our study seeks to find out if that's the case with HZO caused by the varicella zoster virus as well," Dr. Cohen said. The study will include centers across the U.S., Canada, and New Zealand. Timeline for oral antivirals after dermatological eruption Dr. de Luise said that even if a patient presents more than 72 hours after having had the cuta- neous eruption, it is still strongly recommended to give a full, 1-week course of an oral antiviral, acyclovir, famciclovir, or valacyclovir. Dr. Cohen said that oral antivirals can be used if the patient still has an active rash, but if it is scarred or scabbed over, you might not want to use these antivirals. Are oral steroids ever indicated in HZO management? Dr. de Luise said that two large, controlled studies from the 1990s evaluated the addition of oral corticosteroids to acyclovir therapy. Com- pared to antiviral agents alone, the combined regimen was found to accelerate the resolution of acute neuritis and provided an improvement in quality of life metrics. 1,2 Dr. de Luise added that in immunocompro- mised hosts or in patients with diabetes melli- tus, oral steroids can rarely cause viral dissem- ination by lowering the immune response. If oral steroids are to be used in the management of HZO, it's recommended to reserve them for severe cases with acute pain along with the cutaneous eruption; use lower doses, initiate therapy a few days after oral antivirals, and discontinue oral steroids after completing oral antivirals. The oral antivirals lower the viral load and the risk of viral dissemination if the oral steroids are added. Dr. Cohen discussed the "controversy" about the use of oral steroids. "Generally, they're used less than in the past," she said. She thinks steroids are indicated if you have involvement of the optic nerve or orbital inflammation, "but most of the time for herpes zoster ophthalmic- us, we do not use oral steroids," she said. There is some evidence that they might reduce acute pain but no long-term benefit, and there is a risk that they could make infection worse. She said patients should be on antivirals if they're taking oral steroids during the zoster episode. Topical corticosteroids for HZO anterior segment disease Topical corticosteroids are used frequently in HZO, Dr. Cohen said, and many people may have to be on a low dose for a long time be- cause if you go below a certain amount, the eye disease will flare up. Dr. Cohen said that she had HZO in 2008 and still needs a low dose of topical steroids a few times a week to prevent recurrent inflammation in the eye. Topical corticosteroids in HZO anterior segment disease should be used only for corneal and anterior segment manifestations with inflammatory etiology, Dr. de Luise said, such as disciform keratopathy, stromal keratitis, and iri- docyclitis. "Topical corticosteroids do not have efficacy in the setting of pleomorphic, wander- ing epithelial HZO keratitis and are contraindi- cated in HZO epithelial keratitis in patients with HIV/AIDS," he said. IV antivirals Immunocompromised hosts have a much higher likelihood of systemic viral dissemination and should be monitored carefully, with strong consideration of IV antivirals, Dr. de Luise said, adding that IV acyclovir is the first choice. IV foscarnet is the drug of choice in acyclovir-resis- tant herpes zoster, he said. Dr. Cohen said that IV antivirals are often used if you have neurologic involvement at the onset, and she said that you have to be aware that HZO is a risk factor for having a stroke, especially within the first month. IV antivirals are used when there is central nervous system involvement or involvement of cranial nerves or the orbit. continued from page 93

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