The World Cornea Congress IX took place from March 20–22, 2025, in Washington, D.C., drawing over 1,200 ophthalmologists from around the world. Held every five years, this 2-day meeting showcases significant advances in both clinical care and research across the global corneal community. This year’s dynamic program featured symposia, scientific papers, posters, educational courses, exhibits, and valuable networking opportunities.
During the congress, Prof. Elisabeth Cohen, Department of Ophthalmology at NYU Grossman School of Medicine, delivered a presentation on the Management of Zoster Keratitis. In the following Q&A, she shares her clinical insights on diagnosis, treatment strategies, and prevention of this complex and often under-recognized condition.
- What are the key clinical signs that help you distinguish zoster keratitis from other types of viral keratitis in the early stages?
In most cases there is a history of typical unilateral, painful, blistering rash in the distribution of the first branch of the trigeminal nerve that supplies the forehead. Zoster keratitis typically starts two to four weeks after the rash and is associated with dendriform epithelial keratitis (DEK) or stromal keratitis. DEK due to zoster lacks the terminal bulbs associated with keratitis due to herpes simplex virus.
2. When do you typically initiate systemic antiviral therapy, and what duration and dosage do you recommend for immunocompetent vs immunocompromised patients?
Standard treatment is to start therapeutic high dose of valacyclovir, famciclovir or acyclovir preferably within 72 hours of the onset off the rash for 7-10 days. I am not aware of a recommended regimen for immunocompromised persons. Patients with neurological complications or disseminated disease are hospitalized for intravenous acyclovir treatment.
3. What is your preferred treatment strategy for recurrent or chronic zoster keratitis? Are there any prophylactic measures you recommend?
The Zoster Eye Disease Study was a randomized clinical trial to evaluate suppressive valacyclovir in HZO. The results showed that 1 year of valacyclovir compared to placebo significantly reduced episodes of new/worsening keratitis at 18 months, reduced multiple episodes at 12 and 18 months, was more beneficial when started within six months of disease onset, and reduced the dose of neuropathic pain medications. Exploratory analysis showed that episodes of stromal keratitis continue to be treated with an increase in topical steroids.
4. How do you manage ocular surface complications such as neurotrophic keratitisor dry eye in these patients?
These complications are treated using a multi-pronged approach depending on the severity including preservative-free tears, discontinuation of toxic medications, punctal occlusion, autologous serum tears lateral tarsorrhaphy, amniotic membrane transplantation, tissue adhesive and more recently, topical cenegermin recombinant nerve growth factor and corneal neurotization surgery.
5. What’s one thing you wish more general ophthalmologists or optometrists knew about managing zoster keratitis?
Prevention of zoster is the best approach by strongly recommending the two-shot series of recombinant zoster vaccine to all adults age 50 years and older and immunocompromised adults age 19 years and older in accordance with CDC recommendations.
Interested in learning more about the World Cornea Congress IX? Take a look at the full programme here.
Support: No fees or funding were associated with the publication of this short article.
Cite: Cohen E. Clinical pearls from WCC IX: Managing zoster keratitis. touchOPHTHALMOLOGY. March 28th, 2025.
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