Welcome to Review of Optometry's Practice Pearl of the Week series. Optometrist Paul Karpecki will provide you invaluable clinical information and management strategies for a host of ocular conditions—from dry eye and corneal infection to retinal artery occlusion and neuro-ophthalmic disease.

The key is to get the patient on oral anti-viral therapy as soon as possible. Often, the sooner a patient is treated, the better the course and outcome.

There are three primary options for treatment:

• 800mg oral acyclovir five times/day.
• 1,000mg oral valacyclovir (Valtrex, GlaxoSmithKline) three times/day.
• 500mg oral famciclovir (Famvir, Novartis) three times/day.

These three treatment options have been proven to work effectively, and produce few (if any) side effects. So, which one is the best choice?

Oral acyclovir is the least expensive medication. However, valacyclovir is now available in generic form, so it is no longer much more expensive than acyclovir. Furthermore valacyclovir is 35% more bioavailable than acyclovir because it is a prodrug. Finally, valacyclovir is dosed just three times/day compared to five times/day for acyclovir.

But, there is one particular instance in which either valacyclovir or famciclovir definitely are better treatment options than acyclovir: If a patient presents to you after the initial 72-hour period from the time of initial symptom onset (the acute phase of the disease). Studies have shown that waiting until after the 72-hour window did not substantially affect the efficacy of valacyclovir, but did adversely affect the action of other drugs, such as acyclovir.¹

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