Antivirals versus steroids for treatment of herpes zoster related ophthalmoplegia: A case series and systematic review

Authors: Irina Sverdlichenko, Safwan Tayeb, Kirill Zaslavsky, Jonathan Micieli, Edward
Margolin. University of Toronto.

Author Disclosures: Irina Sverdlichenko: None Safwan Tayeb: None Kirill Zaslavsky: None Jonathan Micieli: None Edward Margolin: None
 

Abstract Body: 

Purpose: Herpes zoster infection is caused by varicella zoster virus. It occurs in individuals who were exposed to the virus, either through natural infection or vaccination. Some patients with herpes zoster develop herpes zoster ophthalmicus, which involves reactivation of the virus in the ophthalmic division of the trigeminal nerve. Up to 1/3 of patients with herpes zoster ophthalmicus may develop ophthalmoplegia. While zoster‐related ophthalmoplegia (ZO) is typically treated with antiviral agents, there is controversy regarding the therapeutic role of systemic steroids. This study investigates the use of antivirals alone versus antivirals and steroids for the treatment of ZO. 

Study Design: Retrospective case series and case‐report‐based systematic review

Methods: For the case series, participants were recruited from tertiary neuro‐ophthalmology clinics. Eligible participants were those who developed cranial nerve palsies (CNP) within one month of HZO diagnosis. The systematic review followed PRISMA guidelines. MEDLINE, EMBASE and Cochrane CENTRAL were searched from inception to February 2022 for original studies reporting on adults with ZO who were treated with antivirals or steroids only, or combination therapy. Main outcomes were initial presentation, investigations, neuroimaging, treatment regimen and final outcomes of ophthalmoplegia. University research ethics board approval was obtained and this study follows the tenets of the Declaration of Helsinki. 

Results: Eleven immunocompetent patients with ZO were included. The most common CNP was CN III (5/11), followed by CN VI (2/11) and CN IV (2/11). One patient had multiple CNPs. All patients were treated with antivirals and four were also treated with a short course of oral steroids. At six‐months follow‐up, 75% of patients treated with combination therapy and 85.7% of patients treated with antivirals alone had complete recovery of ZO. The systematic review identified 63 studies consisting of 76 cases of ZO. When comparing patients treated with antivirals to those treated with antivirals and steroids, patients on combination therapy had more severe ocular findings, including complete ophthalmoplegia (p<0.001). Age was the only significant predictor of complete recovery of ophthalmoplegia on multivariable logistic regression (p=0.037).

Conclusions: The rate of complete recovery in immunocompetent patients with ZO was similar in patients treated with antivirals alone versus those treated with antivirals and oral steroids. The systematic literature review affirmed these findings. However, age may influence recovery of ophthalmoplegia.

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