Herpes zoster ophthalmicus

ICD-10 Diagnosis Code

B02.39–Other herpes zoster eye disease


Herpes Zoster Dermatitis of Eyelid

Herpes Zoster  (1)

Herpes zoster ophthalmicus is a dermalogical and neurologic disorder caused by the varicella-zoster virus.

Initial Symptoms of Herpes Zoster Ophthalmicus

  • Localized skin rash within 72-hours of virus reactivation
  • Skin discomfort
  • Active vesicular skin lesions
  • Parathesias (tingling sensations)
  • All of the above usually respecting the midline

The herpes zoster virus in its primary form causes varicella or chickenpox.  After the primary infection, the virus remains in the dorsal root or other sensory ganglion and may lay dormant for years or decades.  

Aging, immunosuppressive illness, new stress, or medical treatment can cause a reactivation of the latent varicelal-zoster virus.  Reactivation is characterized by a localized skin rash erupting in a single dermatome called herpes zoster or shingles.

Structural Damage to the Eye and Adnexa

  • Vesicular skin rash on the eyelids can lead to scarring
  • Corneal scarring can result from infiltrates, stromal edema, or neovascularization
  • Corneal ulcers can cause the cornea to become necrotic
  • Chronic inflammation secondary to the viral infection can result in structural damage to the cornea

Functional Damage to the Eye

  • Profound vision loss due to corneal scarring
  • Profound vision loss secondary to corneal necrosis

The main goal of the diagnostic evaluation in a patient with herpes zoster ophthalmicus is to accomplish the following:

  • Determine the precise onset of the reactiviation of the virus
  • Identify and exclude differential diagnoses
  • Prescribe a treatment program

To obtain the information required to determine a clinical diagnosis of herpes zoster ophthalmicus and to prescribe a treatment plan, the following service components of a medical eye examinaion should be performed. 

  • Patient history
  • General medical observation
  • External examination
  • Adnexal examination
  • External ocular examination with biomicroscopy
  • Ophthalmoscopy
  • Intraocular pressures

Patient History

Patients with herpes zoster ophthalmicus may present with any of the following abnormal clinical signs and symptoms.

  • Vesicular skin rash respecting the midline
  • Varying degree of pain
  • Redness (usually unilateral)
  • Foreign body sensation
  • Tearing
  • Itchy eyes
  • Swelling of the eyelids
  • Blurred vision
  • Fever
  • Malaise

External Examination

A face-to-face inspection of the external ocular and facial areas.

Clinical Appearance of the Skin

  • Vesicles respecting the midline of the 5th trigeminal dermatome
  • Severe skin rash respecting the midline of the 5th trigeminal dermatome
Clinical Appearance of the Skin

  • The external ocular and facial area will reveal a vesicular skin rash on the forehead or the upper eyelid in mild cases or early in the natural history of the disease
  • The preauricular lymph nodes should be examined by palpation and any abnormalities such as swelling or tenderness should be noted
Clinical Appearance of the Skin

  • Acute skin rash is characterized by active vesicles on an erythematous base respecting the midline

Adnexal Examination

  • Preauricular lymphadenopathy may be present

External Ocular Examination with Biomicroscopy

Clinical Appearance of the Cornea

  • Pseudodentrites may stain mildly with fluorescein
  • Stromal keratitis stromal edema
  • Corneal ulceration
  • Corneal scarring
  • Anterior chamber reaction
  • Elevation in intraocular pressure secondary to uveitis



The ophthalmoscopic examination may reveal some of the clinical signs of herpes zoster opthalmicus – especially in patients that are immunocompromised.

Clinical Appearance of the Retina

  • Optic Neuritis
  • Optic Papillitis

Clinical Appearance of the Retina

  • Posterior pole reaction indicating retinitis
  • Posterior pole reaction indicating choroiditis

No specific classification is in place for herpes zoster ophthalmicus.

Herpes simplex virus

The rash associated with herpes simplex does not respect the midline or follow a dermatome.  These patients are usually younger.  The corneal dendrites of Herpes simplex do have true terminal bulbs and will stain well with fluorescein, while the pseudodendrites of Herpes zoster do not have true terminal bulbs and stains poorly with fluorescein.  

Corneal Ulcer 

The symptoms of pain, discomfort and photophobia are similar, but patients with ulcers also report redness, watery eyes or mucopurulent discharge as well.  Usually there is a history of contact lens wear or some form of trauma left untreated to develop into a corneal ulcer.

Corneal Abrasion

A corneal abrasion at any level can sometimes appear necrotic as well.  A corneal abrasion that is healing can be mistaken for a pseudodendritic staining ulcer. Case history is very relevant to differentiate.  A preauricular node will not be present for patients with a corneal abrasion.

Cluster Headaches 

Sometimes the pain from cluster headaches can mimic skin discomfort and paresthesias.  Cluster headaches will not have the accompanying ocular symptoms.

Migraine Headaches 

Migraines can also cause pain in and around the eye, skin discomfort and paresthesias.  Migraines may or may not be accompanied by visual auras that last about 30 minutes to an hour.  Patients other senses may also be heightened or affected during the episode of migraines. 

The key to treating herpes zoster ophthalmicus is making an early diagnosis while administering systemic, topical and ophthalmic pharmacologic agents as indicated by the severity of the condition.

Early diagnosis is within 72 hours of viral reactivation (e.g., acute skin rash with active lesions present).

Systemic Pharmacologic Treatment for Skin Involvement

  • Acyclovir 800 mg orally 5x / day for 7-10 days; or, 
  • Famcyclovir 500 mg orally 3x / day for 7-10 days; or, 
  • Valcyclovir 1000 mg orally 3x / day for 7-10 days

Topical Pharmacologic Treatment for Skin Involvement

  • Bacitracin or erythromycin ointment applied to the skin lesions 2x / day for 7-10 days

 Treatment for Skin Involvement

  • Warm compress to the periocular skin to keep the area clean 3x / day for 7-10 days

Topical and Systemic Pharmacologic Treatment for Ocular Involvement

  • Non-preservative artificial tears can be used in mild forms of herpes zoster ophthalmicus to lubricate the ocular surface
  • Prophylactic antibiotic ointment/drops for secondary infections
  • Topical steroids to control corneal pseudodendrites, superficial punctate keratitis, neurotrophic keratitis or anterior chamber reactions.
  • Topical cycloplegic agent for moderate anterior chamber reactions
  • Pain may be severe in the initial two weeks.  Analgesics may be recommended.  Monitor for post herpetic neuralgia which can have an early onset and last for years.

1.  Potter W.  An Overview of Ocular Herpetic Disease.  May 2010. http://www.reviewofoptometry.com/continuing_education/tabviewtest/lessonid/106745/.  Last accessed January 20, 2015.
2.  Sowka J. Kabat A.  The ‘Other’ Ocular Herpes.  RevOptom.  15 July 2009. http://www.revoptom.com/content/d/therapeutic_review/i/786/c/14565/.  Last accessed August 17, 2014.

Other herpes zoster eye disease

External ocular photography


The prevalence of Herpes zoster ophthalmicus is 0-25% of the all herpes zoster cases.


  • Herpes zoster has a slightly higher prevalence in women than men
  • Herpes zoster has a highter prevalence in Caucasians vs. African-Americans
  • Herpes zoster ophthalmicus does not seem to correlate with age, gender, or severity of condition

Risk Factors

  • Herpes zoster increases dramatically with age
  • Herpes zoster increases with immunocompromised individuals