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Antiviral Medications for the Eye

Topical and oral antivirals used for HSV and herpes zoster eye disease

Herpetic Eye Disease: HSV & HZO Antiviral Therapy

A practical framework for herpetic eye disease

Antiviral management is driven by two questions: which virus (HSV vs. varicella-zoster) and which layer is involved (epithelium vs. stromal / endothelial / uveitic disease). HSV epithelial keratitis is treated to stop active viral replication and close the epithelial defect. In contrast, HSV stromal or endothelial disease is largely immune-mediated and often requires topical steroid with concurrent antiviral coverage to reduce the risk of epithelial reactivation.

Herpes zoster ophthalmicus (HZO) requires prompt systemic antiviral therapy, ideally started early after rash onset, to reduce ocular complications and help mitigate post-herpetic neuralgia. Topical antivirals usually have a limited role in HZO compared with HSV epithelial disease.

HSV epithelial keratitis (dendritic and geographic ulcers)

The classic presentation is a dendritic ulcer: a branching epithelial defect with terminal bulbs that stains with fluorescein, often with rose bengal or lissamine staining of devitalized epithelium. Treatment goals are to halt viral replication, promote re-epithelialization, and reduce progression to a geographic ulcer or stromal involvement.

Topical antiviral therapy: Ganciclovir 0.15% gel is commonly favored for HSV epithelial disease due to good tolerability and convenient dosing. Continue through epithelial closure, then taper per response and clinical protocol.

Oral antiviral therapy: Oral acyclovir, valacyclovir, or famciclovir are effective options and avoid additional surface toxicity. Selection is individualized based on age, renal function, adherence considerations, and local practice patterns. Dose and duration should follow current labeling and institutional guidance.

Avoid topical steroids in active epithelial HSV disease (dendritic/geographic ulcers), as steroids can promote viral replication and enlarge epithelial defects.

HSV stromal, endothelial, and uveitic disease

Stromal keratitis (necrotizing or immune stromal), endothelial involvement (disciform keratitis), and HSV-associated anterior uveitis are typically driven by inflammation and immune response. These phenotypes often require a carefully monitored topical steroid to control inflammation and limit scarring, but they should be paired with concurrent antiviral coverage (commonly oral) to reduce the risk of epithelial reactivation.

Management decisions (timing, taper, duration) depend on severity, corneal findings, IOP, recurrence history, and follow-up reliability. Co-management is appropriate when disease is severe, atypical, recurrent, or threatening the visual axis.

Herpes zoster ophthalmicus (HZO)

HZO involves the ophthalmic (V1) distribution of the trigeminal nerve and requires systemic antiviral therapy to reduce viral replication and ocular complications. Benefit is greatest when therapy starts early after rash onset. Unlike HSV epithelial disease, topical antivirals are not routinely central to HZO care; treatment is typically high-dose oral antiviral therapy tailored to renal function, age, and comorbid conditions. Coordinate with primary care, urgent care, or neurology for severe pain, systemic involvement, or complex cases.

Ophthalmic Antivirals

BrandGenericDosingAmountAgesPregnancyMechanism
Famvir
GenericPO
famciclovir250mg po tid x7d (simplex)500mg po tid x7d (zoster)125/250/500mgNABguanine analogue
Valtrex
GenericPO
valcyclovir500mg po tid (simplex)1g po tid x7d (zoster)500mg/1g>12 yearsBguanine analogue
Viroptic
Generic
trifluridine 1%q2h 24-48h, then qid7.5mL>6 yearsCDNA synthesis interference
Zirgan
Generic
ganciclovir 0.15%5x/d, then tid x7d5g (gel)>2 yearsCDNA synthesis interference
Zovirax
GenericPO
acyclovir400mg po 5x/d x7d (simplex)800mg po 5x/d x7d (zoster)200/400/800mg>2 yearsBinhibits DNA polymerase

Ophthalmic Antiviral FAQs

Do oral antivirals require dose adjustment in kidney disease?

Yes. Acyclovir and valacyclovir are primarily renally cleared, so reduced kidney function can increase drug exposure and the risk of adverse effects (including neurotoxicity). In chronic kidney disease, older adults, dehydration, or when creatinine/eGFR is abnormal, adjust the dose and/or interval using current renal dosing recommendations and recent labs. When uncertainty exists, coordinate with the patient's primary care clinician or pharmacist.

When should antivirals be started for herpes zoster ophthalmicus (HZO)?

Start systemic antiviral therapy as early as possible after rash onset, because benefit is greatest when treatment begins within the first few days. Early therapy reduces viral replication and is associated with fewer ocular complications; regimen choice is individualized to renal function, age, and comorbidities.

When are topical steroids appropriate in HSV keratitis?

Steroids are generally avoided in active epithelial HSV (dendritic or geographic ulcers). They are commonly used in stromal or endothelial HSV (including disciform keratitis) and HSV-associated anterior uveitis to control inflammation, but should be paired with concurrent antiviral coverage to reduce the risk of epithelial reactivation. Close follow-up and a thoughtful taper are key.

When is long-term antiviral prophylaxis considered for HSV eye disease?

Long-term oral suppression is considered when recurrence risk is high or the consequences of recurrence are vision-threatening. Common scenarios include:

  • Recurrent stromal keratitis or HSV-associated uveitis.
  • Frequent epithelial recurrences that impair function or reliably recur over time.
  • History of HSV in post-keratoplasty patients where recurrence may compromise graft survival.

Duration and dosing are individualized to recurrence pattern, adverse effect risk (especially renal considerations), and co-management preferences.

How do ganciclovir gel and trifluridine compare for HSV epithelial keratitis?

Ganciclovir 0.15% gel is commonly preferred because it tends to be better tolerated by the corneal epithelium and is typically dosed less frequently, which can improve adherence. Trifluridine remains an option when ganciclovir is unavailable or cost-prohibitive, but it is more likely to cause surface toxicity with intensive dosing and should be monitored closely and tapered as healing occurs.