Herpes zoster ophthalmicus

Pertinent questions when taking the history

• When did the pain and the rash start? The day the rash appeared is day zero for antiviral timing.
• Does the eye hurt, look red, water, feel sensitive to light, or see less clearly than usual? These make ophthalmic involvement more likely.
• Any headache, confusion, weakness, trouble speaking, or double vision? Neurologic spread may require IV antiviral therapy and inpatient care.
• Has the patient had a prior episode of shingles, or prior herpes eye disease? Recurrences are possible.
• Does the patient wear contact lenses? A lens in the affected eye should be removed.
• Is the patient pregnant, or do they live with a newborn, someone who is pregnant, or a person who is immunocompromised?
• Is the patient immunocompromised? Ask about HIV, transplant, chemotherapy, blood cancers, biologics or JAK inhibitors, and long term steroids.
• What is the kidney function? Acyclovir, valacyclovir, and famciclovir all need renal dose adjustment.

Visual vital signs

Vision, pressure, and pupils, recorded and handed off like any other vital sign. In herpes zoster ophthalmicus they show whether the virus has reached the eye and how widespread the involvement may be.

Describe the focused anatomy

• Map the rashV1 zoster covers the forehead, the scalp up to the crown, and the upper eyelid on one side, and stops at the midline. If lesions extend beyond a dermatome, consider primary herpes infection rather than zoster, cellulitis, or disseminated viral disease.
• Nose and lid marginsLook for vesicles on the tip, side, or root of the nose (Hutchinson sign) and on the eyelid margins.
• Lower eyelidA rash limited to the cheek and lower eyelid usually reflects V2 disease, and eye involvement is less likely because the eye is supplied by V1. It is not ruled out, so still check the vision and stain the cornea.
• Eyelids and conjunctivaSwelling, redness, discharge. Describe whether the white of the eye is injected all over or mainly around the cornea.
• CorneaAfter fluorescein, describe fine punctate staining or branching lesions. Zoster pseudodendrites look raised and stain faintly, while herpes simplex dendrites are true ulcers with bulb like ends. If you cannot tell them apart, call it a branching lesion and let ophthalmology sort it out.
• Anterior chamberIs it clear, or hazy? A hazy chamber or layered white cells suggest significant inflammation.

Supporting imaging and tests, if needed

• Usually noneHerpes zoster ophthalmicus is a clinical diagnosis.
• Kidney functionConsider a basic metabolic panel for creatinine based antiviral dosing in older patients and in anyone receiving IV acyclovir.
• When the picture is atypical or severeExternal photographs shared with the consulting ophthalmologist may help if the diagnosis is uncertain. Consider VZV PCR when the diagnosis is uncertain. Obtain bacterial cultures when bacterial keratitis or a secondary bacterial infection is suspected. Obtain a CT of the orbits for proptosis, restricted eye movements, or suspected orbital cellulitis.

Treatment

• Oral antiviralValacyclovir 1 g three times daily for 7 days, acyclovir 800 mg five times daily for 7 to 10 days, or famciclovir 500 mg three times daily for 7 days. Start as early as possible, ideally within 72 hours of the rash. Treat even after 72 hours if new lesions are still forming, the eye is involved, or the patient is immunocompromised; this is a consensus recommendation, since the drug labels have no data beyond 72 hours.Source: Colin 2000 and Tyring 2001, randomized trials in HZO; Werner 2017, European consensus guideline, for starting after 72 hours
• IV acyclovir and admission10 mg/kg every 8 hours with good hydration; use ideal body weight in obese patients. Use for significant immunocompromise with severe or eye involving disease, disseminated zoster, neurologic involvement such as encephalitis or vasculopathy, suspected acute retinal necrosis (ophthalmology will direct the regimen, IV or high dose oral), or a patient who cannot take oral medication.Source: acyclovir injection label; Werner 2017 for disseminated, neurologic, and visceral disease; Schoenberger 2017, AAO report, for acute retinal necrosis

Adjust for kidney function

Adult label thresholds, creatinine clearance in mL/min. From the FDA labels for each drug.

Around the eye

• SteroidsAdding an oral steroid course is case dependent, and clinician judgment should guide therapy; oral steroids have not been shown to prevent postherpetic neuralgia. If ophthalmic involvement is suspected, the point of care clinician should not start topical or routine systemic steroids. Topical steroids for stromal keratitis, endotheliitis, or uveitis are started by ophthalmology, always with systemic antiviral cover, and are avoided in epithelial disease.Source: Werner 2017 and Gross 2020, European and German consensus guidelines; Jiang 2023, Cochrane review
• When the eye is involvedTopical antivirals do not replace oral treatment, and any eye drops are an ophthalmology decision. For epithelial pseudodendrites, ophthalmology may add ganciclovir 0.15% gel, or trifluridine 1% if it is unavailable. Practice varies: European guidelines apply topical aciclovir to every case, while US clinicians rarely use topical antivirals. Avoid topical ophthalmic steroids unless specifically ordered and monitored by the consulting ophthalmologist.Source: Aggarwal 2014, four patient case series; Werner 2017; Lu 2024
• Pain controlAcetaminophen or an NSAID first, with a short opioid course if needed. Keep topical anesthetics off open blisters and away from the eyelids and eye. Lidocaine patches are labeled for postherpetic neuralgia on healed, intact skin. Chilled artificial tears or erythromycin ointment may relieve ocular discomfort. Apply thicker ointments after any therapeutic drops, so the ointment does not block delivery of the medication. Gabapentin may modestly reduce acute zoster pain but has not been shown to prevent postherpetic neuralgia, and the evidence for pregabalin is thinner. Dose for kidney function and watch for sedation in older adults.Source: Werner 2017; Li 2024 and Menaldi 2022, systematic reviews; lidocaine patch label
• Never send home anesthetic dropsDo not give proparacaine or tetracaine for home use or pain relief. Repeated use causes toxic keratopathy, with severe vision loss and, in some patients, the need for a corneal transplant.Source: Yagci 2011, 26 eyes; Yeniad 2010, 8 cases
• Infection controlMonitor and treat for bacterial superinfection. An immunocompetent patient with a localized rash is contagious through contact with blister fluid: cover lesions where possible and use standard precautions until everything has crusted. If facial lesions cannot be covered, follow your facility's infection prevention guidance. An immunocompromised patient needs airborne and contact precautions until dissemination is ruled out. Disseminated zoster needs airborne and contact precautions for the duration of illness. Susceptible healthcare personnel should avoid direct care when immune caregivers are available.Source: CDC Isolation Precautions, Appendix A

Follow up

• AntiviralComplete the full course. Ophthalmology may later add a year of low dose valacyclovir for patients who have had keratitis or iritis. The main trial missed its 12 month primary endpoint, but secondary analyses favored treatment at 18 months and for repeat flares. That is a specialist decision, not an emergency one.Source: Cohen 2025, Zoster Eye Disease Study
• Interval, proposed ASOT triageWith a red flag, ophthalmology the same day. All other new herpes zoster ophthalmicus, ophthalmology within one to two days. No trial defines the optimal interval. Eye disease can appear or return weeks to months later, so any new eye symptom warrants re-evaluation.
• Return precautionsTell the patient to come back for vision change, worsening eye pain or light sensitivity, a spreading rash, severe headache, confusion, weakness, facial droop, or trouble speaking.