Shingles in the eye is a serious condition that can threaten vision. A recent analysis looked at whether taking daily oral antivirals could prevent a specific complication called stromal keratitis. This inflammation affects the cornea and can cause scarring. The researchers followed 527 patients for 12 months to see if the daily medication made a difference. They compared those taking the drug to those taking a placebo. The main goal was to protect sight by stopping the inflammation before it started. The results showed no difference in vision between the two groups. Stromal keratitis happened in 105 of the 527 participants regardless of the pill they took. This means the daily antiviral did not stop the inflammation from developing. The study also tracked how doctors treated the inflammation once it appeared. About 50 percent of patients received steroid eye drops. The type of steroid mattered less than the timing of the treatment. Many patients who stopped steroids earlier had to restart them later. This suggests that watching the eye closely is more important than the daily pill. The team found that low-potency steroid drops were a safe option for managing the inflammation. Patients generally kept good vision when doctors monitored them carefully. The study confirms that the daily antiviral alone is not enough to prevent this specific eye problem. Doctors should focus on recognizing the signs early and treating them quickly with drops.
Valacyclovir No Better Than Placebo for Stromal Keratitis in Herpes Zoster OphthalmicusOral antivirals do not prevent eye inflammation in shingles patients
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Key Takeaway
Consider that oral valacyclovir does not reduce stromal keratitis in HZO; close monitoring and topical steroids are key.
This secondary analysis of a randomized clinical trial evaluated the role of oral valacyclovir in preventing stromal keratitis (SK) among 527 patients with herpes zoster ophthalmicus (HZO). Participants received either oral valacyclovir 1 g daily or placebo and were followed for 12 months.
The primary outcome was visual acuity at 12 months, which showed no difference between groups (logMAR 0.13 ± 0.2). Recurrent, new, or worsening SK occurred in 105 of 527 participants (20%), but randomization group was not associated with SK occurrence. Among the 105 SK episodes, 79 (75%) were recognized at scheduled study visits. Masked investigators treated 11 of 105 instances (10%) with open-label oral antiviral.
Regarding topical steroid use, 52 of 105 participants (50%) received topical steroids at SK complication. Among those, 21 of 47 (45%) used high-potency steroids and 26 of 47 (55%) used low-potency steroids (P = .47). Notably, 48 of 105 participants (47%) received no topical steroids at SK complication. Of those, 18 of 48 (38%) had discontinued steroids in the prior 3 months, and 38 of 48 (75%) were subsequently treated with high-potency steroids twice daily or more. Among low-potency steroid users, 23 of 26 (88%) required only increased frequency.
Safety data were not reported. Limitations include the post-hoc nature of the analysis and lack of statistical testing for many comparisons. Clinically, patients with HZO who develop SK generally maintain very good vision without oral antiviral therapy when monitored closely. Low-potency topical steroids should be considered for treatment and suppression of SK.
What this means for you:
Daily antivirals do not prevent eye inflammation, but close monitoring and steroid drops help manage it. 
View Original Abstract ↓
PURPOSE: To report on the presentation, treatment, and visual outcome of stromal keratitis (SK) in the Zoster Eye Disease Study (ZEDS).
DESIGN: Secondary analysis of SK end point of randomized clinical trial.
SUBJECTS: Patients with herpes zoster ophthalmicus (HZO) were randomized in a double-masked clinical trial of oral valacyclovir 1 g daily or placebo for 1 year. They were followed prospectively every 3 months for 18 months for end points of SK, iritis (IR), endothelial keratitis (EK), or dendritiform epithelial keratitis (DEK).
METHODS: Presentation of recurrent, new, or worsening SK was evaluated retrospectively by treatment assignment, randomization strata, and use of topical steroids. Investigators had been allowed discretionary treatment of end points including open-label valacyclovir and topical steroids. Visual outcome and treatment with open-label oral valacyclovir and topical steroids were evaluated.
MAIN OUTCOME MEASURES: Use of open-label valacyclovir and topical steroid treatment of recurrent, new, or worsening SK, and visual acuity at 12 months.
RESULTS: Recurrent, new, or worsening SK occurred in 105 of 527 participants (20%). The randomization group was not associated with this complication. Mean best-corrected visual acuity at enrollment was logMAR 0.10 ± 0.14 with no difference at 1 year, logMAR 0.13 ± 0.2, and no difference between valacyclovir and placebo groups at enrollment or at 1 year. Among the 105 instances of SK, 79 (75%) were recognized at scheduled study visits rather than at episodic visits. In only 11 of 105 (10%) of recurrent, new, or worsening SK did masked investigators opt to treat with open-label oral antiviral. At the time of SK complication, 52 of 105 participants (50%) were receiving topical steroids, but 47 of 52 participants (90%) receiving topical steroids were using 1× daily or less, 21 of 47 participants (45%) were using high potency, and 26 of 47 participants (55%) were using low potency (P = .47). Of 48 of 105 participants (47%) receiving no topical steroids at recurrent, new, or worsening SK, 18 of 48 (38%) had discontinued steroids in the prior 3 months. A total of 38 of 48 participants (75%) receiving no topical steroids at complication SK were subsequently treated with high-potency steroids 2× daily or more. Of 26 of 52 participants (50%) receiving low-potency steroids at SK complication, 23 of 26 (88%) were treated with increase in frequency only.
CONCLUSIONS: Individuals with ocular complications of HZO who develop SK generally maintain very good vision without the use of oral antiviral therapy when monitored closely and SK is recognized and treated. Low-potency topical steroids should be considered for treatment and ongoing suppression of SK in HZO.
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