Herpes zoster ophthalmicus

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Herpes zoster ophthalmicus
Other names: Ophthalmic zoster
Herpes zoster ophthalmicus.2.jpg
Herpes zoster ophthalmicus
SymptomsRash of the forehead, swelling of the eyelid, pain and red eye[1]
ComplicationsVision loss, chronic pain[2]
CausesReactivation of varicella zoster virus[2]
Risk factorsPoor immune function, psychological stress, older age[2]
Diagnostic methodBased on symptoms[1]
PreventionHerpes zoster vaccine[1]
MedicationAntiviral pills such as acyclovir, steroid eye drops[1]
FrequencyUp to 125,000 per year (US)[3]

Herpes zoster ophthalmicus (HZO), also known as ophthalmic zoster, is shingles involving the eye.[1] Symptoms generally include a rash of the forehead with swelling of the eyelid.[1] There may also be eye pain, eye redness, and light sensitivity.[1] Before the rash appears tingling may occur in the forehead along with a fever.[1][3] Complications may include vision loss, increased pressure within the eye, and chronic pain.[2][1]

The underlying mechanism involves a reactivation of the varicella zoster virus within the ophthalmic nerve (the first division of the trigeminal nerve).[2] Risk factors include poor immune function, psychological stress, and older age.[2] Diagnosis is generally based on symptoms.[1]

Treatment is generally with antiviral pills such as acyclovir.[1] Steroid eye-drops and drops to dilate the pupil may also be used.[1] The herpes zoster vaccine is recommended for prevention in those over the age of 50.[1] Shingles affects up to half a million people in the United States a year of which 10% to 25% involve the eye.[3][2]

Signs and symptoms


Trigeminal shingles with uveitis and keratitis


Herpes zoster ophthalmicus as seen after florescence staining using cobalt blue light
  • Epithelial: punctate epithelial erosions and pseudodendrites: often have anterior stromal infiltrates. Onset 2 to 3 days after the onset of the rash, resolving within 2–3 weeks. Common.
  • Stromal:
    • Nummular keratitis: have anterior stromal granular deposits. Occurs within 10 days of onset of rash. Uncommon
    • Necrotising interstitial keratitis: Characterised by stromal infiltrates, corneal thinning and possibly perforation. Occurs between 3 months and several years after onset of rash. Rare.
  • Disciform Keratitis (Disciform Endotheliitis): a disc of corneal oedema, folds in Descemet's membrane, mild inflammation evident within the anterior chamber and fine keratic precipitates. Chronic. Occurs between 3 months and several years after the onset of the rash. Uncommon.
  • Neurotrophic: corneal nerve damage causes persistent epithelial defect, thinning and even perforation. Cornea becomes susceptible to bacterial and fungal keratitis. Chronic. Late onset. Uncommon.
  • Mucous plaques: linear grey elevations loosely adherent to the underlying diseased epithelium/stroma. Chronic. Onset between 3 months and several years after the onset of the rash.[5]


Anterior uveitis develops in 40–50% of cases with HZO within 2 weeks of onset of the skin rashes. Typical HZO keratitis at least mild iritis, especially if Hutchinson's sign is positive for the presence of vesicles upon the tip of the nose.


This non-granulomatous iridocyclitis is associated with:

HZO uveitis is associated with complications such as iris atrophy and secondary glaucoma are not uncommon. Complicated cataract may develop in the late stages of the disease.


Carotid vessels with complete occlusion arrow

Diagnosis of this condition, Herpes zoster ophthalmicus is done via the following:[6]


Treatment is usually with antivirals such as acyclovir or valacyclovir by mouth.[1] There is uncertainty as to the difference in effect between these two antivirals.[7] Antiviral eye drops have not been found to be useful.[3] These medications work best if started within 3 days of the start of the rash.[2]

Cycloplegics prevent synechiae from forming.


  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 "Herpes Zoster Ophthalmicus - Eye Disorders". Merck Manuals Professional Edition. Archived from the original on 12 August 2016. Retrieved 21 December 2019.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 Shaikh S, Ta CN (November 2002). "Evaluation and management of herpes zoster ophthalmicus". American Family Physician. 66 (9): 1723–30. PMID 12449270.
  3. 3.0 3.1 3.2 3.3 "Herpetic Corneal Infections: Herpes Zoster Ophthalmicus". www.aao.org. Archived from the original on 15 August 2020. Retrieved 21 December 2019.
  4. 4.0 4.1 Khurana AK (2008). Comprehensive Ophthalmology. ISBN 9781905740789. Archived from the original on 2021-08-28. Retrieved 2020-01-07.
  5. 5.0 5.1 Denniston, Alastair K. O.; Murray, Philip I. (2009-06-11). Oxford Handbook of Ophthalmology. ISBN 9780199552641. Archived from the original on 2021-08-29. Retrieved 2020-01-07.
  6. Minor, Megan; Payne, Ethan (2021). "Herpes Zoster Ophthalmicus". StatPearls. StatPearls Publishing. Archived from the original on 10 January 2022. Retrieved 16 December 2021.
  7. Schuster AK, Harder BC, Schlichtenbrede FC, Jarczok MN, Tesarz J (November 2016). Cochrane Eyes and Vision Group (ed.). "Valacyclovir versus acyclovir for the treatment of herpes zoster ophthalmicus in immunocompetent patients". The Cochrane Database of Systematic Reviews. 11: CD011503. doi:10.1002/14651858.CD011503.pub2. PMC 6464932. PMID 27841441.

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