Ophthalmic Herpes Zoster (Shingles of the Eye)
Overview
Ophthalmic herpes zoster, also called herpes zoster ophthalmicus (HZO), is a reactivation of the varicella‑zoster virus (VZV) that involves the ophthalmic branch (V1) of the trigeminal (cranial nerve V) nerve. When VZV reawakens, it travels along sensory fibers to the skin and mucous membranes of the eye and surrounding areas, producing a painful rash and, in many cases, inflammation inside the eye.
While anyone who has had chickenpox (or a varicella vaccine) can develop shingles, HZO accounts for only about 10–15 % of all shingles cases.1 The condition most commonly affects adults over 50, with the incidence rising sharply after age 60. Immunocompromised patients—such as those with HIV, cancer, organ transplants, or on chronic steroids—are also at markedly increased risk.
Symptoms
Symptoms usually appear in a classic “dermatomal” pattern, meaning they follow the distribution of the ophthalmic division of the trigeminal nerve. The rash often begins with a prodrome of pain or tingling before skin changes become visible.
Cutaneous (skin) manifestations
- Pain, burning, or itching: May precede the rash by 1‑5 days.
- Vesicular rash: Groups of fluid‑filled blisters that later crust over. Typically located on the forehead, scalp, upper eyelid, and sometimes the tip of the nose (Hutchinson’s sign).
- Redness and swelling: Affected skin may appear erythematous and warm.
Ocular (eye) manifestations
- Conjunctivitis: Red, watery eye.
- Keratitis: Inflammation of the cornea causing pain, photophobia, blurred vision, and a gritty sensation.
- Episcleritis / Scleritis: Redness deeper than conjunctivitis, sometimes painful.
- Uveitis: Inflammation of the middle layer of the eye (iris & ciliary body) leading to blurry vision, floaters, and light sensitivity.
- Retinitis / Chorioretinitis: Inflammation of the retina or choroid, potentially causing permanent vision loss.
- Glaucoma: Elevated intra‑ocular pressure due to trabecular meshwork blockage.
- Optic neuritis: Sudden loss of vision in the affected eye.
Systemic symptoms
- Fever, malaise, headache.
- Swollen lymph nodes near the ear or jaw.
Causes and Risk Factors
What causes ophthalmic herpes zoster?
VZV remains dormant in dorsal root or cranial nerve ganglia after primary infection (chickenpox). Factors that depress cell‑mediated immunity can trigger the virus to reactivate, travel down the ophthalmic branch (V1) of the trigeminal nerve, and cause ocular disease.
Key risk factors
- Age ≥ 50 years: Immunosenescence reduces T‑cell surveillance.
- Immunosuppression: HIV/AIDS, chemotherapy, long‑term corticosteroids, biologic agents.
- Previous shingles episode: Recurrence is uncommon but possible.
- Chronic diseases: Diabetes, chronic lung disease, renal failure.
- Physical or emotional stress: May temporarily dampen immunity.
- Vaccination status: Lack of shingles vaccine (Shingrix®) increases risk.
Diagnosis
Prompt recognition is critical because ocular involvement can progress rapidly.
Clinical evaluation
- History: Recent prodromal pain, prior chickenpox, immunocompromise.
- Physical exam: Characteristic unilateral vesicular rash in V1 distribution; check for Hutchinson’s sign (lesions on the tip of the nose), which predicts ocular involvement in > 70 % of cases.2
- Slit‑lamp examination: By an ophthalmologist to detect keratitis, uveitis, or other intra‑ocular inflammation.
Laboratory / imaging tests
- Polymerase chain reaction (PCR): Swab of vesicle fluid can confirm VZV DNA; useful when the rash is atypical.
- Direct fluorescent antibody (DFA) testing: Rapid but less sensitive than PCR.
- Serology: Generally not required because most adults have VZV antibodies.
- Ocular imaging: Optical coherence tomography (OCT) or fluorescein angiography to assess retinal or corneal involvement.
Treatment Options
Therapy aims to reduce viral replication, control inflammation, and prevent vision‑threatening complications.
Antiviral medications (first‑line)
| Drug | Typical adult dose | Duration | Notes |
|---|---|---|---|
| Acyclovir | 800 mg orally five times daily | 7–10 days | Renal dosing adjustment needed |
| Valacyclovir | 1 g orally three times daily | 7 days | Better bioavailability; preferred for most patients |
| Famciclovir | 500 mg orally three times daily | 7 days | Alternative if valacyclovir unavailable |
| IV Acyclovir | 10 mg/kg every 8 h | 10–14 days | Severe ocular disease or immunocompromised patients |
Antivirals are most effective when started within 72 hours of rash onset.3
Corticosteroids
- Topical prednisolone acetate 1 % drops: Reduces corneal inflammation; usually started after antiviral therapy is underway.
- Oral prednisone: May be prescribed for severe uveitis or optic neuritis, tapered over 2–4 weeks.
Adjunctive eye‑care
- Artificial tears or lubricating ointments for dryness.
- Topical antibiotics (e.g., ofloxacin) if secondary bacterial infection is suspected.
- Cycloplegic drops (e.g., atropine) to relieve ciliary spasm in uveitis.
Procedural interventions (when needed)
- Corneal debridement: Rarely used to reduce viral load.
- Laser trabeculoplasty: For VZV‑induced glaucoma not responding to medications.
- Vitrectomy: In cases of retinal detachment or persistent vitritis.
Lifestyle & supportive measures
- Stay well‑hydrated and rest.
- Avoid rubbing the eyes; this can spread virus to the contralateral eye.
- Good hand hygiene—wash hands frequently, especially after touching lesions.
Living with Ophthalmic Herpes Zoster
Daily management tips
- Medication adherence: Set alarms or use a pill‑box to ensure you finish the full antiviral course.
- Eye protection: Wear sunglasses to reduce photophobia and shield the eye from dust.
- Cold compresses: Apply a clean, cool, moist cloth to the forehead/eye area for relief, but never place ice directly on the eye.
- Monitor vision: Keep a simple log of any changes (blurred vision, new floaters, pain) and report promptly.
- Follow‑up appointments: Ophthalmology visits are usually scheduled at 1‑week, 2‑weeks, and then monthly until inflammation resolves.
- Nutrition: A balanced diet rich in vitamins A, C, E, and zinc supports ocular health and immune recovery.
- Stress reduction: Techniques such as deep breathing, gentle yoga, or meditation can aid immune function.
Psychosocial considerations
Visible facial rash and fear of vision loss can cause anxiety or depression. Seek support from mental‑health professionals, patient support groups, or counseling services if needed.
Prevention
Vaccination
- Shingrix® (recombinant zoster vaccine): Recommended for adults ≥ 50 years, even if previously vaccinated with Zostavax®. Two doses, 2‑6 months apart, > 90 % efficacy in preventing shingles and post‑herpetic neuralgia.4
- Adults 19–49 years with immunocompromise should also be offered Shingrix®.
General measures
- Maintain a healthy immune system – regular exercise, adequate sleep (7‑9 h), balanced diet.
- Avoid close contact with individuals who have active shingles lesions, especially if you are immunosuppressed.
- Control chronic diseases (diabetes, hypertension) to reduce overall infection risk.
Complications
If left untreated or inadequately managed, HZO can lead to serious, sometimes irreversible, eye damage.
- Vision loss: Due to corneal scarring, stromal keratitis, or retinal necrosis.
- Post‑herpetic neuralgia (PHN): Persistent facial pain lasting > 3 months after rash resolution; occurs in ~10–20 % of HZO patients.5
- Chronic ocular hypertension / glaucoma: May require lifelong pressure‑lowering therapy.
- Secondary bacterial infection: Superinfection of the skin or cornea.
- Scarring of the eyelid (ectropion) or conjunctiva: Can cause exposure keratopathy.
- Neurologic sequelae: Cranial nerve palsies, meningitis, or encephalitis (rare).
When to Seek Emergency Care
- Sudden loss of vision in the affected eye.
- Severe eye pain that does not improve with medication.
- Marked swelling around the eye with fever > 38.5 °C (101.5 °F).
- Sudden onset of double vision (diplopia) or eye movement limitation.
- Signs of acute glaucoma: halos around lights, a hard eye on gentle palpation, nausea/vomiting.
- Rapidly spreading rash into the other eye or the opposite side of the face.
References
- Centers for Disease Control and Prevention. “Shingles (Herpes Zoster) – About.” CDC.
- Kim J, et al. “Ophthalmic herpes zoster: clinical features and outcomes.” Ophthalmology. 2016;123(5):1062‑1070. PMID: 26838302.
- CDC. “Shingles Treatment.” CDC.
- CDC. “Shingles (Herpes Zoster) Vaccine – Shingrix.” CDC.
- Mayo Clinic. “Shingles (herpes zoster) – Symptoms and causes.” Mayo Clinic.