OVERVIEW

What is ocular shingles?

Ocular shingles (herpes zoster ophthalmicus, HZO) refers to a series of conditions caused by infection of ocular tissues (including the eyeball and its appendages) with the varicella-zoster virus (VZV). It commonly affects individuals who are physically weak, elderly, or immunocompromised.

It can manifest as herpes zoster of the eyelids, as well as herpetic conjunctivitis, keratitis, scleritis, or iridocyclitis. Among these, herpes zoster of the eyelids and herpetic keratitis are more frequently observed.

Treatment primarily involves antiviral medications and corticosteroids, with surgical intervention rarely required. If not treated promptly, it may severely threaten vision.

Is ocular shingles common?

Studies across different populations indicate that the incidence of ocular shingles among shingles patients ranges from 8% to 56%. The conjunctiva, cornea, sclera, and even the iris can be affected.

SYMPTOMS

What are the main symptoms of ocular herpes zoster?

Ocular herpes zoster has many different types, but the vast majority first appear as herpes zoster on the eyelids.

The most common symptoms are pain in the eyelid skin or combined with the skin of the forehead, often presenting as severe neuropathic pain, accompanied by symptoms such as photophobia, tearing, and skin redness and swelling.

Most patients will subsequently develop clustered transparent small blisters on the skin, arranged in a band-like pattern, which then become turbid and form pustules, eventually rupturing, eroding, and drying into scabs.

Some patients may develop complications such as herpes zoster conjunctivitis, scleritis, keratitis, or even iritis. Inflammation in different areas will have distinct symptoms, generally including eye redness, stinging pain, difficulty opening the eyes, and vision loss, among others.

How is ocular herpes zoster distributed when it occurs on the eyelids?

It generally affects the upper eyelids and forehead, sometimes appearing on the lower eyelids, facial skin, or upper lip skin. It typically occurs only on one side of the face and does not cross the midline of the face.

Can ocular herpes zoster on the eyelids cause sequelae?

Possibly.

• Postherpetic neuralgia: Pain may persist even after the herpes zoster improves, lasting 1–2 months or sometimes several years before disappearing. After healing, it may leave behind sensory dullness or numbness.
• Hyperpigmentation: After the blisters scab and fall off, hyperpigmentation or even superficial scars may remain. In some cases, the blisters may become infected, forming deep ulcers that leave permanent scars after healing.

Can ocular herpes zoster cause sequelae?

Herpes zoster affecting the conjunctiva and sclera generally causes congestion and pain, with no significant sequelae after healing.

However, herpes zoster on the cornea may lead to corneal epithelial damage, ulcers, and decreased corneal sensitivity, potentially leaving behind corneal nebula, macula, leukoma, or stromal opacity, which can affect future vision.

Although herpes zoster of the iris and ciliary body is relatively rare, it may result in sequelae such as posterior synechiae, secondary glaucoma, and complicated cataracts.

CAUSES

What pathogen causes ocular herpes zoster?

It is the varicella-zoster virus (VZV). This virus should actually be very familiar to everyone, as it is the pathogen that causes chickenpox.

VZV infection can cause two clinically distinct diseases.

• Primary VZV infection causes chickenpox, characterized by vesicular skin lesions at different stages on the face, trunk, and limbs. Afterward, VZV remains latent in the body, waiting for an opportunity to reactivate.
• When latent VZV in sensory ganglia reactivates, it causes herpes zoster (shingles), characterized by painful unilateral vesicular eruptions that follow a dermatomal distribution, forming a band-like pattern.

Why does ocular herpes zoster occur?

It is generally believed that VZV lies dormant in the ophthalmic branch of the trigeminal nerve. When the body's immunity declines—particularly due to triggers such as lack of sleep, catching a cold, or fatigue—VZV can reactivate, stimulating tissue inflammation and inducing corresponding symptoms and signs.

Herpes zoster, including ocular herpes zoster, is more common in elderly individuals, those with chronic illnesses, or those using immunosuppressive medications, as their immune systems are relatively weaker.

Is ocular herpes zoster contagious?

It depends.

Herpes zoster is caused by the varicella-zoster virus. A primary infection with this virus may either be asymptomatic or result in chickenpox. The virus then remains latent in the body, and only when immunity declines does it reactivate, manifesting as herpes zoster.

Therefore, individuals who have never been infected with VZV or have not received the chickenpox vaccine may develop chickenpox (but not herpes zoster) after exposure to someone with herpes zoster. Those who have already been infected with VZV or have been vaccinated against chickenpox will not be reinfected after exposure.

People who have never had chickenpox or received the chickenpox vaccine should be especially cautious around individuals with herpes zoster. Avoid touching the patient's rash, as this could lead to chickenpox. In rare cases, merely being near a herpes zoster patient may result in chickenpox.

DIAGNOSIS

How is ocular herpes zoster diagnosed?

During diagnosis, doctors primarily rely on medical history + symptoms + physical signs.

• Medical history: The doctor conducts an inquiry to determine if there are typical factors triggering herpes zoster.
• Symptoms: Mainly refer to irritation in the eyelid skin and eyeball, including redness, swelling, blisters, pain, etc.
• Physical signs: The doctor examines the patient to observe whether there are blisters on the eyelid skin, redness in the conjunctiva or sclera, epithelial damage to the cornea, or active inflammation in the anterior chamber.

After confirming ocular herpes zoster on the eyelid, what additional tests are needed?

• A slit-lamp examination is generally required. This helps observe whether there is redness in the conjunctiva or sclera to rule out their involvement.
• The cornea must be checked for edema or epithelial damage to exclude herpes zoster keratitis.
• The presence of corneal precipitates or active inflammation in the anterior chamber, including aqueous flare and cells, should be assessed to rule out iridocyclitis.

TREATMENT

Which department should I see for ocular herpes zoster?

Ophthalmology, Dermatology.

How is ocular herpes zoster treated?

• Mainly antiviral therapy, commonly used drugs include acyclovir, valacyclovir, and famciclovir, to inhibit VZV replication.
• In addition, oral corticosteroids such as prednisone can be used to suppress inflammatory reactions.
• For severe pain, oral painkillers may provide some relief.
• For patients with postherpetic neuralgia, medications like pregabalin can be used to inhibit nerve pain.
• At the same time, local eye treatments can be supplemented, such as:
  • Using steroid eye drops to reduce inflammation and control immune-related keratitis and iritis.
  • For patients with corneal epithelial damage, eye drops or gels that promote epithelial healing can be used.
  • For patients with iridocyclitis, cycloplegic eye drops or ointments are needed to dilate the pupil and prevent glaucoma.
• Surgery is rarely required, but corneal transplantation or eyelid reconstruction may be performed if necessary to treat sequelae.

Does ocular herpes zoster require hospitalization?

Generally, patients with severe active lesions requiring urgent treatment need hospitalization.

Those with severe eyelid or forehead skin lesions but mild eye symptoms may consider dermatology admission. If ocular symptoms, especially keratitis or iridocyclitis, are present, ophthalmology admission is recommended.

DIET & LIFESTYLE

What dietary precautions should patients with ocular shingles take?

Strengthening dietary nutrition is beneficial for the recovery of shingles. Pay attention to appropriately supplementing proteins such as meat, eggs, and milk, and eat more fresh vegetables and fruits.

What lifestyle precautions should patients with ocular shingles take?

• Get adequate rest, ensure sufficient sleep, and avoid fatigue.
• Avoid contact with infants and young children to prevent transmission.
• Closely monitor changes in the condition during treatment to take proactive measures.

How should patients with ocular shingles care for their skin?

• Keep the skin clean and avoid applying ointments randomly.
• Do not puncture the blisters with needles.
• Avoid rubbing the skin to prevent worsening pain.

PREVENTION

Can ocular herpes zoster be prevented? How to prevent ocular herpes zoster?

Avoid predisposing factors such as fatigue, staying up late, catching cold, etc.

If you have not had chickenpox and there are patients with chickenpox or herpes zoster around, take precautions to avoid contact.