Herpes Zoster Ophthalmicus

Herpes zoster infection, often known as shingles, is a common viral infection that occurs when the chickenpox virus (varicella zoster) reactivates later in life.

When the herpes zoster infection affects a nerve in the face called the ophthalmic nerve, it is called herpes zoster ophthalmicus, or ophthalmic shingles.

There are around 1 million cases of shingles each year in the United States, 1 up to 25 percent of which are herpes zoster ophthalmicus. 2

People who have previously had chickenpox are at risk of developing herpes zoster ophthalmicus. It most commonly affects older people and people with a weakened immune system.

The typical symptoms of ophthalmic shingles are:

• Painful, blistering rash over the face and eye- Eye pain and redness on the same side as the rash.

If you are concerned that you may have this condition, try using the Ada app to find out more about your symptoms.

Ophthalmic shingles is typically treated using antiviral medications, which may need to be given through a drip (intravenously) if symptoms are severe.

If not treated adequately and quickly, herpes zoster ophthalmicus can cause permanent vision problems, such as:

• Glaucoma
• Cataracts
• Blindness

It is important to see a doctor without delay if the symptoms of herpes zoster ophthalmicus appear .

Ophthalmic shingles often begins with a tingling, burning pain over the eye, forehead, temple and nose. This is followed up to a week later by a blistering rash: 3 4

• The rash is vesicular; vesicles are small, blister-like sacs that appear on the surface of the skin
• The skin around the vesicular rash becomes red
• The rash is generally confined to one side of the face. In people with weakened immune systems, the rash may be more widespread
• The rash blisters burst and scab over, usually seven to 10 days after first appearing
• The rash generally goes away after two to four weeks

Good to know: People with this condition are contagious until the rash has scabbed over.

As well as the rash, people with herpes zoster ophthalmicus often develop:

• A painful, watering eye on the same side as the rash
• Swelling around the eye
• In some cases, ocular problems

Worried you may have herpes zoster ophthalmicus? You can try using the Ada app for a free assessment.

People with shingles may also experience:

• Headache
• Fever
• Chills
• Loss of appetite

Read more about Signs of Shingles »

Only those who have previously had chickenpox are at risk of developing shingles or ophthalmic shingles. Herpes zoster infection occurs years, sometimes decades, after a person has been infected with the varicella zoster virus that causes chickenpox.

The virus remains dormant (inactive) in the nervous system and can reactivate if a person’s immunity to varicella zoster weakens over time, either due to age or if another condition causes a person’s immune system to weaken. Stress and/or illness may trigger a reactivation of the virus.

In ophthalmic shingles, the virus reactivates in the trigeminal ganglion, a cluster of nerves located to the sides and base of the skull. The trigeminal ganglion is connected to the opthalmic nerve. If the virus reactivates, it travels up the nerve to the skin and the eye, and this is how the infection affects the eye. 4

People with weakened immune systems are more likely to develop herpes zoster ophthalmicus than the general population. A weakened immune system may be the result of various conditions, such as:

• Chemotherapy for cancer
• Leukemia
• HIV infection
• Immunosuppressive drugs taken before or after an organ transplant
• Long-term use of certain drugs, such as steroids

Good to know: People with any of the above-mentioned conditions or any other form of weakened immune system should avoid contact with someone with an active case of shingles, herpes zoster ophthalmicus or chickenpox. Pregnant women and unvaccinated children or adults should also avoid people with an active case of shingles.

A diagnosis can usually be made based on the symptoms and the appearance of the rash, as well as through an examination of the eye. If uncertain, the diagnosis can be confirmed with blood tests or by taking a sample of fluid from a blister and testing for the virus.

An ophthalmologist should examine the eye for signs of corneal disease and other eye problems. 5

Ophthalmic shingles should be treated urgently with oral antiviral medication, which helps to manage the pain and reduces the risk of complications occurring. Drugs often prescribed to treat ophthalmic shingles include: 6

• Acyclovir
• Famciclovir
• Valacyclovir

People who have a weakened immune system or who develop severe vision problems may need to receive acyclovir intravenously (through a drip).

Eye drops containing corticosteroids may also be needed. They should be taken with care due to the potential of an increased risk of eye complications such as keratitis. 4

Anti-inflammatory medications, such as ibuprofen, or other analgesics, may help reduce the pain and swelling.

People with shingles should try to avoid scratching at the rash. Calamine lotion and wet compresses can help soothe the itching. It is important to consult a medical practitioner before putting anything on or in the eye, and it is very important to avoid scratching the eye or the area around the eye, as bacterial infections may occur and lead to complications.

Possible complications of herpes zoster ophthalmicus include: 2 7 8

• Conjunctivitis: Inflammation of the lining of the eye
• Keratitis: Inflammation of the cornea, which could lead to visual impairment
• Blepharitis: Inflammation of the eyelid
• Uveitis: Inflammation of the iris and ciliary body 9 in the eye
• Episcleritis: Inflammation of a clear layer over the white of the eye
• Scleritis: A serious condition in which the white of the eye becomes inflamed
• Retinal necrosis: This can produce pain and/or blurred vision, and can ultimately lead to blindness

People with weakened immune systems are more likely to develop ocular complications from ophthalmic shingles.

Some people with herpes zoster ophthalmicus will experience postherpetic neuralgia (PHN), which is pain that lasts after the rash and blisters disappear. Symptoms include: 2 4

• Pain in the eye and area of the face affected by herpes zoster ophthalmicus. This may be constant or intermittent.
• Allodynia, which is when pain is triggered by non-painful stimuli, such as light touch or wind blowing on the face.

The number of people who will experience postherpetic neuralgia ranges from 10 to 30 percent. 4

The experience of living with postherpetic neuralgia may affect a person’s mental health, for example it can increase the risk of clinical depression.

People who have shingles should keep away from people who have not been vaccinated against chickenpox (especially newborns and young children, as well as pregnant people) and people who have a weak immune system.

Good to know: Although shingles itself cannot be passed from person to person, the varicella zoster virus which causes chickenpox can be transmitted through contact with the fluid in the rash blisters. 10

Vaccination against chickenpox (the varicella vaccination) and herpes zoster (a herpes zoster vaccination) can help to prevent and reduce the severity of some cases of shingles.

The Centers for Disease Control and Prevention recommends that all healthy adults aged 50 and older should receive the shingles vaccine. Depending on the age of the person receiving the vaccine, it is between 89 and 97 percent effective at preventing shingles and postherpetic neuralgia. 11 12

• Shingles affecting the eye
• Zoster Ophthalmicus
• Ophthalmic shingles

(Herpes Zoster Virus Ophthalmicus; Ophthalmic Herpes Zoster; Varicella-Zoster Virus Ophthalmicus)”](https://www.msdmanuals.com/home/eye-disorders/corneal-disorders/herpes-zoster-ophthalmicus). October 2018. Accessed 29 December 2018.

Q: Is herpes zoster ophthalmicus contagious?
A: Herpes zoster ophthalmicus itself is not contagious. However, it is possible for someone with this condition to pass on the varicella virus that causes chickenpox through contact with fluid from the rash blisters.

Q: Is herpes zoster ophthalmicus the same as herpes keratitis?
A: Herpes keratitis is caused by the herpes simplex virus, the same virus which causes cold sores and genital herpes. Infection can be spread to the eye by touching an active lesion and then the eye. It specifically affects the cornea of the eye and symptoms include:

• Pain
• Redness
• A Rash
• Blurred vision

Herpes keratitis can lead to permanent vision problems.

Herpes zoster ophthalmicus is caused by the varicella virus which causes chickenpox. The virus stays dormant in the body and can later reactivate and cause herpes zoster, otherwise known as shingles. Sometimes shingles affects the eye, and can cause keratitis as a complication.

Q: Can herpes zoster ophthalmicus cause long-term problems for the eye?
A: Herpes zoster ophthalmicus, if not adequately treated, can cause:

• Glaucoma
• Cataracts
• Scarring inside the eye

These are long-term problems requiring management and, in some cases, surgery. Additionally, if a secondary bacterial skin infection develops, the eye may be damaged, and that damage may affect vision. 13

Q: Can herpes zoster ophthalmicus cause light sensitivity?
A: Yes. Light sensitivity, also called photosensitivity, is a common symptom of herpes zoster ophthalmicus, along with: 14

• Redness
• Swelling of the eyelid
• Pain in and around the eye

Q: Is it safe to wear contact lenses during an episode of herpes zoster ophthalmicus?
A: No. People with herpes zoster ophthalmicus should not wear their usual prescription contact lenses while the condition is present, but should switch to wearing glasses. Contact lenses may increase the risk of developing a secondary bacterial infection, 15 as well as being uncomfortable. In some cases, however, special contact lenses may be used for treatment, usually in combination with antibiotic eye-drops. ref15

Q: Can herpes zoster ophthalmicus cause blindness?
A: Yes, although this is a rare complication 16 17 and is very unlikely to occur if the condition is properly treated. Blindness is more likely in cases where a secondary bacterial infection of the affected eyeball and skin causes inflammation of the tissues in that area. 13 Abscesses are a common complication of secondary bacterial inflammation.

Glaucoma and cataracts are other complications of herpes zoster ophthalmicus that may also lead to blindness if not treated. 13

Q: What are the symptoms of herpes simplex keratitis?
A: Herpes simplex keratitis is caused by the herpes simplex virus, not the varicella zoster virus. Symptoms include: 18

• Pain in or around one eye
• Redness of the eye
• A feeling that grit, dust or dirt is in the eye
• A very watery eye
• Swelling and/or cloudiness of the cornea
• Vision problems
• Sensitivity to light

The symptoms of herpes simplex keratitis are quite similar to those of herpes zoster ophthalmicus, but there is no shingles rash on the face or head in cases of herpes simplex keratitis. 18