Herpes zoster ophthalmicus (HZO), also known as ophthalmic zoster, is

shingles Shingles, also known as herpes zoster or zona, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. T ...

involving the

eye An eye is a sensory organ that allows an organism to perceive visual information. It detects light and converts it into electro-chemical impulses in neurons (neurones). It is part of an organism's visual system. In higher organisms, the ey ...

or the surrounding area. Common signs include a

rash A rash is a change of the skin that affects its color, appearance, or texture. A rash may be localized in one part of the body, or affect all the skin. Rashes may cause the skin to change color, itch, become warm, bumpy, chapped, dry, cracke ...

of the forehead with swelling of the eyelid. There may also be eye pain and redness, inflammation of the conjunctiva,

cornea The cornea is the transparency (optics), transparent front part of the eyeball which covers the Iris (anatomy), iris, pupil, and Anterior chamber of eyeball, anterior chamber. Along with the anterior chamber and Lens (anatomy), lens, the cornea ...

uvea The uvea (; derived from meaning "grape"), also called the uveal layer, uveal coat, uveal tract, vascular tunic or vascular layer, is the pigmented middle layer of the three concentric layers that make up an eye, precisely between the inne ...

, and sensitivity to light. Fever and tingling of the skin and

allodynia Allodynia is a condition in which pain is caused by a stimulus that does not normally elicit pain. For example, sunburn can cause temporary allodynia, so that usually painless stimuli, such as wearing clothing or running cold or warm water over ...

near the eye may precede the rash. Complications may include

visual impairment Visual or vision impairment (VI or VIP) is the partial or total inability of visual perception. In the absence of treatment such as corrective eyewear, assistive devices, and medical treatment, visual impairment may cause the individual difficul ...

, increased pressure within the eye,

chronic pain Chronic pain is pain that persists or recurs for longer than 3 months.https://icd.who.int/browse/2025-01/mms/en#1581976053 It is also known as gradual burning pain, electrical pain, throbbing pain, and nauseating pain. This type of pain is in cont ...

, and

stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...

. The underlying mechanism involves a reactivation of the

latent Latency or latent may refer to: Engineering * Latency (engineering), a measure of the time delay experienced by a system ** Latency (audio), the delay between the moment an audio signal is triggered and the moment it is produced or received ** Mec ...

varicella zoster virus Varicella zoster virus (VZV), also known as human herpesvirus 3 (HHV-3, HHV3), is one of nine known herpes viruses that can infect humans. It causes chickenpox (varicella) commonly affecting children and young adults, and shingles (herpes zos ...

(VZV) within the

trigeminal ganglion The trigeminal ganglion (also known as: Gasserian ganglion, semilunar ganglion, or Gasser's ganglion) is the sensory ganglion of each trigeminal nerve (CN V). The trigeminal ganglion is located within the trigeminal cave (Meckel's cave), a cav ...

supplying the

ophthalmic nerve The ophthalmic nerve (CN V1) is a sensory nerve of the head. It is one of three divisions of the trigeminal nerve (CN V), a cranial nerve. It has three major branches which provide sensory innervation to the eye, and the skin of the upper face ...

(the first division of the

trigeminal nerve In neuroanatomy, the trigeminal nerve (literal translation, lit. ''triplet'' nerve), also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for Sense, sensation in the face and motor functions ...

). Diagnosis is generally based on signs and symptoms. Alternatively, fluid collected from the rash may be analyzed for VZV DNA using

real-time PCR A real-time polymerase chain reaction (real-time PCR, or qPCR when used quantitatively) is a laboratory technique of molecular biology based on the polymerase chain reaction (PCR). It monitors the amplification of a targeted DNA molecule duri ...

. This test is rapid, easy to perform, and is highly sensitive and specific method for diagnosing this condition. Treatment is generally with antiviral pills such as

acyclovir Aciclovir, also known as acyclovir, is an antiviral medication. It is primarily used for the treatment of herpes simplex virus infections, chickenpox, and shingles. Other uses include the prevention of cytomegalovirus infections following tran ...

. Steroid eye drops and drops to dilate the pupil may also be used. The herpes zoster vaccine is recommended for prevention in those over the age of 50. HZO is the second most common manifestation of shingles, the first being involvement of skin of the thorax. Shingles affects up to one half million people in the United States per year, of which 10% to 25% is HZO.

Signs and symptoms

Skin

Trigeminal herpes with uveitis and keratitis

* Viral

prodrome In medicine, a prodrome is an early sign or symptom (or set of signs and symptoms, referred to as prodromal symptoms) that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. More specifically, it ...

* Preherpetic neuralgia * Rash, transitioning from

papule A papule is a small, well-defined bump in the skin lesion, skin. It may have a rounded, pointed or flat top, and may have a umbilication, dip. It can appear with a Peduncle (anatomy), stalk, be thread-like or look warty. It can be soft or firm a ...

s to

vesicle Vesicle may refer to: ; In cellular biology or chemistry * Vesicle (biology and chemistry), a supramolecular assembly of lipid molecules, like a cell membrane * Synaptic vesicle ; In human embryology * Vesicle (embryology), bulge-like features ...

s to

pustule A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this ...

s to scabs. * Hutchinson's sign:

cutaneous Skin is the layer of usually soft, flexible outer tissue covering the body of a vertebrate animal, with three main functions: protection, regulation, and sensation. Other animal coverings, such as the arthropod exoskeleton, have different d ...

involvement of the tip of the nose, indicating

nasociliary nerve The nasociliary nerve is a branch of the ophthalmic nerve (CN V1) (which is in turn a branch of the trigeminal nerve (CN V)). It is intermediate in size between the other two branches of the ophthalmic nerve, the frontal nerve and lacrimal ner ...

involvement. While a positive Hutchinson's sign increases the likelihood of ocular complications associated with HZO, its absence does not rule out ophthalmic involvement. * Disseminated distribution in individuals with

immunodeficiency Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that aff ...

Cornea

* Epithelial: punctate epithelial erosions and pseudodendrites: often have anterior stromal infiltrates. Onset 2 to 3 days after the onset of the rash, resolving within 2–3 weeks. Common. * Stromal: **

Nummular keratitis Nummular keratitis is a feature of viral keratoconjunctivitis. It is a common feature of adenoviral keratoconjunctivitis (an ocular Adenoviridae, adenovirus infection), as well as approximately 1/3rd of cases of Ophthalmic zoster, Herpes Zoster O ...

: have anterior stromal granular deposits. Occurs within 10 days of onset of rash. Uncommon ** Necrotising interstitial keratitis: Characterised by stromal infiltrates, corneal thinning and possibly perforation. Occurs between 3 months and several years after the onset of rash. Rare. * Disciform Keratitis (''Disciform Endotheliitis''): a disc of corneal oedema, folds in

Descemet's membrane Descemet's membrane ( or the Descemet membrane) is the basement membrane that lies between the corneal proper substance, also called stroma, and the endothelial layer of the cornea. It is composed of different kinds of collagen (Type IV and VIII ...

, mild inflammation evident within the

anterior chamber The anterior chamber ( AC) is the aqueous humor-filled space inside the eye between the iris and the cornea's innermost surface, the endothelium. Hyphema, anterior uveitis and glaucoma are three main pathologies in this area. In hyphema, ...

and fine

keratic precipitate Keratic precipitate (KP) is an inflammatory cellular deposit seen on corneal endothelium. Acute KPs are white and round in shape whereas old KPs are faded and irregular in shape. Mutton-fat KPs are large in shape and are greasy-white in color an ...

s. Chronic. Occurs between 3 months and several years after the onset of the rash. Uncommon. *

Neurotrophic Neurotrophic factors (NTFs) are a family of biomolecules – nearly all of which are peptides or small proteins – that support the growth, survival, and differentiation of both developing and mature neurons. Most NTFs exert their trop ...

: corneal nerve damage causes a persistent epithelial defect, thinning and even perforation. The cornea becomes susceptible to bacterial and fungal

keratitis Keratitis is a condition in which the human eye, eye's cornea, the clear dome on the front surface of the eye, becomes inflammation, inflamed. The condition is often marked by moderate to intense pain and usually involves any of the following sy ...

. Chronic. Late onset. Uncommon. * Mucous plaques: linear grey elevations loosely adherent to the underlying diseased epithelium/stroma. Chronic. Onset between 3 months and several years after the onset of the rash.

Uveal

Anterior uveitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and i ...

develops in 40–50% of people with HZO within 2 weeks of the onset of the skin rashes. Typical HZO keratitis at least mild

iritis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and i ...

, especially if Hutchinson's sign is positive for the presence of

s upon the tip of the nose. Features: This non-

granulomatous A granuloma is an aggregation of macrophages (along with other cells) that forms in response to chronic inflammation. This occurs when the immune system attempts to isolate foreign substances that it is otherwise unable to eliminate. Such subst ...

iridocyclitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and i ...

is associated with: * Small

s * Mild

aqueous flare The Tyndall effect is light scattering by particles in a colloid such as a very fine suspension (a sol). Also known as Tyndall scattering, it is similar to Rayleigh scattering, in that the intensity of the scattered light is inversely proporti ...

* Occasionally haemorrhagic

hypopyon Hypopyon is a medical condition involving Inflammation#Cellular component, inflammatory cells in the anterior chamber of the human eye, eye. It is an exudate rich in white blood cells, seen in the anterior chamber, usually accompanied by redness ...

HZO

uveitis Uveitis () is inflammation of the uvea, the pigmented layer of the eye between the inner retina and the outer fibrous layer composed of the sclera and cornea. The uvea consists of the middle layer of pigmented vascular structures of the eye and ...

is associated with complications such as iris atrophy and

secondary glaucoma Secondary glaucoma is a collection of progressive optic nerve disorders associated with a rise in intraocular pressure (IOP) which results in the loss of vision. In clinical settings, it is defined as the occurrence of IOP above 21 mmHg requiring t ...

are not uncommon. Complicated

cataract A cataract is a cloudy area in the lens (anatomy), lens of the eye that leads to a visual impairment, decrease in vision of the eye. Cataracts often develop slowly and can affect one or both eyes. Symptoms may include faded colours, blurry or ...

may develop in the late stages of the disease.

Anatomy

HZO is due to reactivation of VZV within the trigeminal ganglion. The trigeminal ganglion give rise to the three divisions of cranial nerve V (CN V), namely the ophthalmic nerve, the maxillary nerve, and the mandibular nerve. VZV reactivation in trigeminal ganglion predominantly affects the ophthalmic nerve, for reasons not clearly known. The ophthalmic nerve gives rise to three branches: the supraorbital nerve, the supratrochlear nerve, and the nasociliary nerve. Any combination of these nerves can be affected in HZO, although the most feared complications occur with nasociliary nerve involvement, due to its innervation of the eye. The supraorbital and supratrochlear nerves mainly innervate the skin of the forehead. The

frontal nerve The frontal nerve is the largest branch of the ophthalmic nerve (V1), itself a branch of the trigeminal nerve (CN V). It supplies sensation to the skin of the forehead, the mucosa of the frontal sinus, and the skin of the upper eyelid. It may be a ...

is more commonly affected than the

lacrimal nerve The lacrimal nerve is the smallest of the three main branches of the ophthalmic nerve (CN V1) (itself a branch of the trigeminal nerve (CN V)). It enters the orbit outside the common tendinous ring and passes forward along the side wall of the ...

Treatment

Treatment is usually with antivirals such as

, valacyclovir, or famcyclovir by mouth. There is uncertainty as to the difference in effect between these three antivirals. Antiviral eye drops have not been found to be useful. These medications work best if started within 3 days of the start of the rash.

Cycloplegics Cycloplegia is paralysis of the ciliary muscle of the eye, resulting in a loss of accommodation. Because of the paralysis of the ciliary muscle, the curvature of the lens can no longer be adjusted to focus on nearby objects. This results in si ...

prevent synechiae from forming.

References

External links

{{Varicella zoster Varicella zoster virus-associated diseases Ophthalmology Wikipedia medicine articles ready to translate