AKT · Ophthalmology/Orbit & infection

Herpes zoster ophthalmicus

VZV reactivation in the ophthalmic (V1) division of the trigeminal nerve

Overview

Reactivation of varicella-zoster virus in the ophthalmic (V1) division of the trigeminal nerve. A painful vesicular dermatomal rash of the forehead/upper lid that may threaten the eye. Hutchinson sign (vesicles on the nose tip — nasociliary nerve) predicts ocular involvement. Treated with oral/IV antivirals; ocular involvement needs ophthalmology.

Recognise

Painful vesicular rash in the V1 dermatome (forehead, upper lid, side of nose), respecting the midline, often with a prodrome
HUTCHINSON SIGN: vesicles on the tip/side of the nose (nasociliary branch) → high risk of eye involvement
Ocular: keratitis (pseudodendrites), anterior uveitis, conjunctivitis, episcleritis, raised IOP, rarely retinitis/optic neuritis

Red flags

Eye redness, pain, photophobia or reduced vision, or Hutchinson sign → ophthalmology assessment for ocular involvement
Immunocompromised/disseminated zoster → IV aciclovir and admission

Differentials & how to tell them apart

HSV keratitistrue dendrites with end-bulbs and no dermatomal rash; HZO gives pseudodendrites + V1 rash

Bacterial periorbital cellulitisno vesicles, not dermatomal

Contact dermatitisitchy, not dermatomal, no true vesicles/pain

Herpes zoster ophthalmicus — V1 dermatomal vesicular rash (Hutchinson sign)
Milorad Dimic, MD / CC BY-SA 3.0 — Wikimedia Commons

Investigations

Clinical. Slit-lamp if any ocular symptom (fluorescein for pseudodendrites, check IOP and AC). Swab for VZV PCR in doubt.

Management

Oral antivirals (within 72 h) + ophthalmology if any ocular involvement/Hutchinson sign

1Start oral antiviral (aciclovir/valaciclovir/famciclovir) promptly, ideally within 72 h. Analgesia. Assess the eye.Gate: Hutchinson sign or ANY ocular symptom → refer to ophthalmology for slit-lamp assessment (keratitis/uveitis/IOP); topical steroids only under specialist care; immunocompromised → IV aciclovir + admit
2Ocular involvement managed by ophthalmology (topical steroid/cycloplegic, IOP control); treat post-herpetic neuralgia (amitriptyline/gabapentin). (Shingles is also a dermatology card — cross-reference.)

Oral antiviral (aciclovir/valaciclovir/famciclovir) — start within 72 h (or while new vesicles forming) to reduce ocular complications and post-herpetic neuralgia

IV aciclovir — immunocompromised, disseminated, or sight-threatening disease

Topical steroid/cycloplegic — specialist — for zoster keratitis/uveitis under ophthalmology

Key points

V1 dermatomal vesicular rash + nose-tip vesicles (Hutchinson) = HZO with high ocular risk. Antivirals within 72 h and an eye check. (The general shingles teaching is on the dermatology page.)

Monitor & prognosis

Eye review while active; watch for post-herpetic neuralgia.

Good with early antivirals; ocular and neuralgic complications if delayed.

Source: NICE CKS Shingles; RCOphth