Herpes zoster (shingles) is a viral disease that produces a painful rash on the skin. The skin rash consists of vesicles (small blisters or lesions) that form scabs. The blisters can result in a permanent scar. Herpes zoster ophthalmicus (HZO) refers to shingles that occur on the area surrounding the eye. It is a devastating form of acute herpes zoster. It can also cause severe eye problems like inflammation, glaucoma and corneal ulcers.
Eye problems for people with herpes zoster may manifest themselves same time as the rash. The problems can also develop weeks after the rash is gone. Some patients may develop keratitis, conjunctivitis, ocular cranial-nerve palsies and uveitis. Other eye conditions associated with HZO include scleritis, episcleritis, glaucoma and retinitis. 
Shingles also cause Ramsay Hunt syndrome which affects the facial nerve near the ear. The disease makes it difficult to close the eyelid. Failure to close the eyelid can damage the clear protective tissue in the cornea. This action may lead to eye pain and blurred vision.

Also Known As

Herpes zoster ophthalmicus (HZO)

Causes and Risk Factors

Varicella-zoster virus (VZV), which is responsible for chickenpox, also causes herpes zoster. The virus can stay in the body for years before it resurfaces as shingles. HZO occurs as a result of a viral invasion of the Gasserian ganglion. It develops when cranial nerve V (trigeminal nerve) is involved in the reactivation of the VZV. Risk factors may include:

  • Old age
  • A weakened immune system
  • Acute lymphocytic leukemia, chronic diseases and other malignancies
  • Inflammatory bowel disease
  • Patients who have been treated with arsenic trioxide for multiple myeloma and colon cancer
  • Cataract surgery 
  • External exposure to the virus
  • Emotional stress

Signs & Symptoms

The symptoms of HZO include:

  • Influenza-like illness with fatigue
  • Fever that appears a week before the rash manifests on the forehead
  • Dermatomal pain in the ophthalmic nerve
  • Conjunctival edema or inflammation
  • Vesicular lesions/yellowish crusting and discharge
  • A periorbital vesicular rash affecting the first division of the fifth cranial nerve 
  • Blisters on one side of the forehead and around the upper eyelid
  • The skin is reddish and extremely sensitive to touch
  • Itching, throbbing and burning around the eye
  • Blurry vision
  • Redness in the eye
  • Teary eye


If there is a rash around the eye, an eye care professional can conduct a visual acuity test to check if vision has been affected. Other tests may include:

  • An external examination of the periocular skin, scalp and eyelids
  • Dilating and examining the macula, optic nerve, peripheral retina, vitreous and lens
  • Measuring intraocular pressure
  • A slit-lamp biomicroscopy of the anterior segment to look for corneal vascularization and staining cornea defects. The stroma capacities and the anterior chamber are also examined

Individuals who have a compromised immune system may require further laboratory testing to confirm the disease. Examples of such tests are:

  • Direct fluorescent antibody testing to test the vesicular fluid and check for a corneal lesion 
  • Polymerase chain reaction testing to test the vesicular fluid, corneal lesion and blood 
  • Tzanck smear test (it involves studying corneal scrapings)


Treatment aims to reduce the severity and duration of HZO.

Medical Treatment

Cases of herpes zoster normally resolve on their own. The eye doctor may prescribe oral antiviral therapy such as acyclovir, valacyclovir and famciclovir. These medications should commence within 72 hours of the appearance of the symptoms. Antiviral therapy decreases the length of time a new vesicle may form.
The doctor can recommend medications to control pain and prevent further skin infection. He/she can prescribe nonsteroidal anti-inflammatory drugs. The patient can also use lotions like calamine and creams such as capsaicin to help with the blisters. 
Topical steroids such as prednisolone acetate may help with interstitial keratitis, intraocular pressure and uveitis. For retinitis, optic neuritis, choroiditis and scleritis, systemic oral steroids or intravenous administration can be given.
Hospital admission should be considered for patients who present severe symptoms of herpes zoster. In addition, patients with ophthalmic involvement and a weak immune system can be admitted.

Surgical Treatment

Lesions that cause severe corneal thinning may require corneal transplantation. In the case of acute retinal necrosis, a vitrectomy or retinal detachment surgery may be performed. For intraocular pressure in glaucoma, a glaucoma filtration surgery is necessary. Cataract surgery may also be required if  treatment with steroids has caused a cataract.


The patient can use wet dressings that contain 5% aluminum acetate. They may apply the dressings for 30 minutes to one hour, 4-6 times a day. This action may offer comfort and promote faster healing of the blisters.

Prognosis/Long-term outlook

Most people will recover from the skin rash without impediments. The symptoms tend to resolve within 10-15 days while the rash may take a month to heal. However, some patients may experience pain for years. The elderly usually recover from pain slowly. 

Herpes zoster rarely causes death but it can be life-threatening in patients with compromised immunity.

HZO can lead to a temporary or permanent decrease in visual acuity or even blindness. 

Herpes zoster can affect any part of the central nervous system. For example, it can produce cranial nerve palsies and Guillain-Barré syndrome.

Orbital edema is an emergency that requires urgent evaluation and treatment. Iritis, glaucoma, corneal tissue ulceration and iridocyclitis may result from HVO. With ocular involvement, long-term antiviral therapy may be necessary. 

The patient in the acute phase should be monitored every 1-7 days. Aggressive monitoring is necessary because of the possibility of eye involvement.

Though rare, it is possible for patients with HVO to transmit the virus.

Prevention/Follow Up

Vaccines such as a live attenuated VZV vaccine (Zostavax) and Shingrix are available to prevent HVO.