Herpes zoster ophthalmicusMANAGEMENT

OPHTHALMOLOGIC PRESENTATIONS · 12 SECTIONS

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614 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Acute angle-closure glaucoma Central retinal artery occlusion Central Retinal Vein Occlusion Chemical eye injury Corneal abrasion Corneal ulcer Endophthalmitis Globe rupture Herpes zoster ophthalmicus Hyphema Iritis-Uveitis Ocular foreign body Optic Neuritis Orbital cellulitis Orbital Floor Fracture (Blowout)Posterior vitreous detachment Retinal detachment Retrobulbar hematoma and orbital compartment syndrome Vitreous Hemorrhage

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp51

Immediate sight-threatening recognition and mandatory exam steps

›Vision-threatening presentation triage

›Vesicular rash in V1 trigeminal distribution

›Forehead, scalp, and upper eyelid

›Rash respects the horizontal midline of the nose and forehead

›Hutchinson sign

›Vesicles on the tip, side, or root of the nose

›Marker of nasociliary nerve involvement and the single strongest predictor of ocular disease

›Any visual complaint with periocular zoster

›Decreased vision

›Photophobia

›Eye pain out of proportion to the lid rash

›Mandatory ED ocular examination in every patient with V1 zoster

›Visual acuity in every affected patient

›Best corrected if correction available

›Compare to the unaffected eye

›Fluorescein staining in every affected patient

›Pseudodendrite versus true epithelial defect distinction

›Perform before any topical anesthetic reaches the patient's hands

›Intraocular pressure measurement in every affected patient

›Compare to the fellow eye and any known baseline

›Detects early secondary glaucoma before symptoms are obvious

Escalation and consultation triggers

›Ophthalmology contact thresholds

›Any Hutchinson sign

›Same-day ophthalmology evaluation regardless of current ocular symptoms

›Any positive fluorescein finding

›Pseudodendrite pattern

02History/hx53

Presentation and timeline

›Symptom chronology

›Prodromal periorbital or forehead pain

›Typically 1 to 5 days before rash

›Pitfall: mimics sinusitis, migraine, or tension headache before vesicles appear

›Rash onset and evolution

›Hours since first vesicle

›Ongoing new lesion formation

›Time since rash onset and antiviral decision

›Within 72 hours of rash onset

›Standard antiviral window for greatest benefit

›Beyond 72 hours of rash onset

›Antiviral therapy still indicated with any ocular involvement

›Antiviral therapy still indicated with ongoing new vesicle formation

›Antiviral therapy still indicated in an immunocompromised host

Hutchinson sign and risk stratification

›Hutchinson sign history

›Vesicles reported on the nose tip, side, or root

›Associated with ocular involvement in approximately 50 to 75% of cases when present

›No nasal lesions reported

›Ocular involvement still occurs in roughly one in four presentations without Hutchinson sign

›Do not use a negative Hutchinson sign to defer ophthalmology referral if any eye symptom is present

›Anatomic basis for the history question

›Nasociliary nerve shared innervation

›External nasal branch supplies the nose tip

›Long ciliary branches supply the cornea and globe

Ocular symptom red flags

›Vision symptoms

03Physical Exam/exam53

Dermatomal and Hutchinson sign exam

›Skin findings

›Unilateral vesicles on an erythematous base in V1 distribution

›Forehead, upper eyelid, and scalp

›Respects the midline

›Hutchinson sign

›Vesicle on the tip, side, or root of the nose

›Document explicitly as present or absent in every case

›Lid findings

›Eyelid edema and vesicles

›Mechanical ptosis from lid edema versus true neurogenic ptosis

Mandatory ocular exam: fluorescein and intraocular pressure

›Fluorescein examination

›Pseudodendrite pattern

›Raised mucous plaque, not a true epithelial ulcer

›Tapered ends without terminal bulbs

›Stains poorly with fluorescein compared to a true dendrite; stains better with rose bengal if available

›True HSV dendrite pattern for comparison

›Branching ulcer with terminal bulbs

›Central fluorescein staining with rose bengal staining along the ulcer edge

›Frank epithelial defect

›Neurotrophic keratopathy concern if corneal sensation is reduced

›Intraocular pressure measurement

›Tonometry in both eyes

›Compare to the fellow eye and any known baseline

›Elevated pressure suggests trabeculitis or secondary glaucoma

›Corneal sensation testing

›Reduced or absent sensation supports neurotrophic keratopathy

04Differential Diagnosis/ddx76

Vision-threatening ocular differentials specific to HZO

›Keratitis

›Zoster pseudodendritic keratitis

›Epithelial stage, typically days 4 to 6 after rash onset

›Stromal keratitis

›Immune mediated, later onset than epithelial disease

›Risk of scarring and chronic disease

›Neurotrophic keratopathy

›Reduced corneal sensation from nerve damage

›Risk of persistent epithelial defect and corneal melt

›Uveitis and secondary glaucoma

›Anterior uveitis

›Trabeculitis mechanism

›Risk of secondary glaucoma

›Secondary glaucoma

›Trabeculitis or inflammatory angle mechanism

›Mechanism and treatment differ from pupillary-block angle-closure glaucoma

›Scleritis

›Deep boring pain

›Sectoral or diffuse injection

›Necrotizing pattern

›Higher risk of scleral thinning and perforation

›Acute retinal necrosis

›Peripheral retinal necrosis with occlusive vasculitis

›Rapid progression to retinal detachment if untreated

›Vitritis

›View-limiting exam

›Optic neuritis or neuropathy

05Laboratory Tests/lt36

Baseline safety labs for antiviral therapy

›Renal function

›Creatinine and estimated GFR

›Guides oral and IV antiviral dose adjustment

›Acyclovir crystalluria and nephrotoxicity risk

›Electrolytes

›Baseline before IV hydration accompanying acyclovir infusion

›Not routine for uncomplicated disease

›No labs required for classic HZO with normal renal history and mild disease

›Clinical diagnosis by rash distribution and ocular exam

Labs for suspected dissemination or immunocompromise

›Screening for immunocompromise

›HIV testing if status unknown

›Complete blood count

›Neutropenia as an immunosuppression clue

›Leukocytosis as a bacterial superinfection clue

›Systemic involvement labs

›Liver enzymes if hepatitis concern with disseminated disease

›C-reactive protein if severe systemic features

›Supportive, not diagnostic

Virologic confirmation

›Lesion testing

›VZV PCR from a vesicle swab for atypical or uncertain cases

›Preferred over viral culture for sensitivity

›Direct fluorescent antibody testing where available

›Faster turnaround, lower sensitivity than PCR

›Ocular fluid testing when performed by ophthalmology

›Aqueous or vitreous PCR for VZV

06Diagnostic Tests/dt37

Scoring Systems

›Symptom and risk tools

›Hutchinson sign as a bedside predictive sign

›Not a formal numeric score, but the single most useful bedside predictor of ocular involvement

›Zoster Brief Pain Inventory

›Pain severity 0 to 10

›Pain interference domains

›Ocular disease severity documentation

›Standardized anterior chamber cell and flare grading when performed by ophthalmology

›Supports longitudinal follow-up

›Not an ED-performed grading

MRI

›Neuro-ophthalmic imaging indications

›Optic neuritis or optic neuropathy concern

›MRI brain and orbits with contrast

›Optic nerve enhancement pattern

›Cranial nerve palsy or orbital apex concern

›Evaluate for orbital inflammation

›Evaluate for a vasculopathic stroke mimic

›CNS complication imaging

›Suspected VZV vasculopathy or stroke

›MRI brain with vessel imaging

›Do not delay antiviral therapy for imaging

›Orbital and sinus imaging indications

›Orbital cellulitis concern

›Proptosis

›Pain with eye movement

07Disposition/dispo27

Discharge pathway

›Outpatient-eligible presentation

›No Hutchinson sign and no ocular symptoms

›Reliable follow-up available

›Mild ocular involvement stable on exam

›Normal intraocular pressure

›No sight-threatening finding

›Required same-day or next-day ophthalmology arrangement

›Any Hutchinson sign

›Any positive fluorescein finding

›Any anterior chamber inflammation

Admission indications

›Inpatient criteria

›Immunocompromised host with HZO

›IV antiviral therapy

›Acute retinal necrosis suspected or confirmed

›IV antiviral therapy

›Urgent vitreoretinal specialist involvement

›Uncontrolled elevated intraocular pressure despite ED therapy

›Risk of optic nerve injury

›Disseminated cutaneous disease

›Airborne plus contact precautions

Transfer criteria

›Higher level of care triggers

›No ophthalmology availability for a suspected sight-threatening finding

›Initiate systemic antiviral therapy before transfer

›Initiate empiric IOP-lowering therapy before transfer if pressure is elevated

›No vitreoretinal specialist availability with acute retinal necrosis concern

08Treatment/t146

Antiviral therapy window and oral dosing

›Treatment window

›Start within 72 hours of rash onset for greatest benefit

›Reduces ocular complication risk from approximately 50% untreated to approximately 20 to 30% with early treatment

›Start regardless of time since onset if any of the following

›Active ocular involvement

›Ongoing new vesicle formation

›Immunocompromised host

›Oral antiviral regimens for the immunocompetent host without severe complications

›Valacyclovir 1000 mg PO three times daily for 7 to 10 days

›Preferred for dosing convenience and adherence

›Renal adjustment, CrCl 30 to 49 mL/min: 1000 mg PO every 12 hours

›Renal adjustment, CrCl 10 to 29 mL/min: 1000 mg PO every 24 hours

›Renal adjustment, CrCl less than 10 mL/min or hemodialysis: 500 mg PO every 24 hours

›Famciclovir 500 mg PO three times daily for 7 to 10 days

›Alternative if valacyclovir is unavailable or not tolerated

›Renal adjustment, CrCl 40 to 59 mL/min: 500 mg PO every 12 hours

›Renal adjustment, CrCl 20 to 39 mL/min: 500 mg PO every 24 hours

›Renal adjustment, CrCl less than 20 mL/min: 250 mg PO every 24 hours

›Acyclovir 800 mg PO five times daily for 7 to 10 days

›Lower bioavailability and higher pill burden than valacyclovir or famciclovir

›Renal adjustment, CrCl 10 to 25 mL/min: 800 mg PO every 8 hours

›Renal adjustment, CrCl less than 10 mL/min: 800 mg PO every 12 hours

›Evidence framing

›Systemic antiviral therapy is standard of care for HZO across ophthalmology and infectious disease guidelines

›Landmark oral acyclovir trial demonstrated reduced ocular complications with early treatment

›No formally published AHA/ACC-style letter grade exists for this ophthalmology-specific recommendation

Intravenous antiviral therapy indications and dosing

›IV therapy indications

›Immunocompromised host

›HIV with low CD4 count

›Transplant, hematologic malignancy, or high-dose corticosteroid use

›Retinal involvement

›Acute retinal necrosis suspected or confirmed

›Disseminated cutaneous disease

›More than 20 lesions outside the primary and adjacent dermatomes

›CNS involvement

›Encephalitis or VZV vasculopathy

›Acyclovir IV dosing

›Acyclovir 10 mg/kg IV every 8 hours

›Infuse over at least 1 hour to reduce nephrotoxicity risk

›Concurrent IV hydration to reduce crystalluria

›Avoid rapid bolus administration

›Renal adjustment, CrCl 25 to 50 mL/min: every 12 hours

›Renal adjustment, CrCl 10 to 25 mL/min: every 24 hours

›Renal adjustment, CrCl less than 10 mL/min: reduced dose every 24 hours per nephrology or pharmacy guidance

›Duration and transition

›Continue IV therapy until clinical improvement

›Transition to oral valacyclovir or famciclovir to complete 10 to 14 days total for disseminated, CNS, or retinal disease

›Monitoring during IV therapy

›Renal function every 24 to 48 hours during the infusion course

›Shorten the interval if creatinine rises

›Urine output monitoring

›Crystalluria and obstructive nephropathy risk

Ocular adjunctive therapy in the ED

›IOP-lowering therapy for secondary glaucoma

›Topical aqueous suppressants

›Timolol 0.5% one drop affected eye twice daily

›Avoid in asthma, COPD, or high-degree AV block

›Dorzolamide 2% one drop affected eye three times daily

›Sulfonamide-related reaction caution

›Brimonidine 0.1 to 0.2% one drop affected eye three times daily

›Avoid in infants due to apnea risk

›Latanoprost 0.005% one drop affected eye nightly avoided in uveitic secondary glaucoma

›Can worsen intraocular inflammation and cystoid macular edema

›Class effect for prostaglandin analogs, not specific to this one agent

›Pilocarpine 1 to 2% one drop avoided in this mechanism

›Mechanism here is trabeculitis with an open angle, not pupillary block

›Miotics increase inflammation and promote posterior synechiae in this mechanism

›Cycloplegic therapy for anterior uveitis

›Cyclopentolate 1% one drop affected eye two to three times daily

›Pain relief from ciliary spasm

›Reduces posterior synechiae formation

›Atropine 1% one drop affected eye once to twice daily for severe inflammation

›Longer duration of action than cyclopentolate

›Systemic anticholinergic effect caution in young children and older adults

›Topical steroid decision boundary

›Never initiated in the ED

›Ophthalmologist-only decision after slit lamp confirmation of epithelial status

›Contraindicated in the presence of an active epithelial defect until specialist assessment

›Prohibited outpatient prescription

›No topical ophthalmic anesthetic sent home with the patient

›Anesthetic abuse keratopathy can progress to corneal melt and perforation

›Use for in-ED examination only

Postherpetic neuralgia and analgesia

›Baseline analgesics

›Acetaminophen 1000 mg PO every 6 hours as needed

›Maximum 3000 mg per day if older age or hepatic risk

›Ibuprofen 400 mg PO every 6 to 8 hours as needed

›Maximum 2400 mg per day typical

›Avoid in CKD or GI bleed risk

›Neuropathic agents for postherpetic neuralgia

›Gabapentin 300 mg PO at bedtime day 1

›Titrate to 300 mg PO twice daily day 2

›Titrate to 300 mg PO three times daily day 3

›Typical target 900 to 1800 mg per day

›Renal dose adjustment required

›Pregabalin 75 mg PO twice daily

›Titrate to 150 mg PO twice daily within 1 week as needed

›Renal dose adjustment required

›Amitriptyline 10 to 25 mg PO nightly

›Obtain baseline ECG for QTc prolongation risk, particularly in older adults or with other QT-prolonging medications

›Avoid in older adults when possible due to anticholinergic burden

›Corneal anesthesia caution with pain control

›Do not rely on topical agents for facial or periorbital neuralgia

›Systemic neuropathic agents are the mainstay

›Avoid any topical ophthalmic anesthetic regardless of pain severity

Antiviral resistance and treatment failure

›Therapy not working

›New or worsening lesions after 72 hours of adequate antiviral dosing and adherence

›Consider acyclovir-resistant VZV, most often in immunocompromised hosts with prior antiviral exposure

›Virology or infectious diseases consultation

›Progressive keratitis or uveitis despite adequate systemic antiviral therapy

›Reassess adherence and confirm the dose was renally appropriate

›Escalate to IV therapy and ophthalmology reassessment

›Resistant VZV management

›Foscarnet 40 mg/kg IV every 8 hours as a specialist-guided alternative

›Renal adjustment required, guided by nephrology or pharmacy

›Requires infectious diseases involvement and inpatient monitoring

›Nephrotoxicity and electrolyte disturbance monitoring, hydrate concurrently

Iatrogenic harms from routine ED interventions

›Airway and sedation

›Intubation

›Not indicated by HZO itself

›If required for another indication, protect and lubricate the affected eye given corneal epithelial vulnerability

›Procedural sedation

›Not routinely needed for HZO

›Tape and lubricate the affected eye if sedation is performed for another reason

›Fluid and oxygen therapy

›Fluid loading

›Not indicated by HZO itself

›Required alongside IV acyclovir to reduce crystalluria and nephrotoxicity, but avoid volume overload in cardiac or renal disease

›Supplemental oxygen

›Not indicated unless pulmonary dissemination is present

›Vasoactive and procedural interventions

›Vasopressors

›Not applicable to HZO unless septic from disseminated superinfection

›Mechanical circulatory support including intra-aortic balloon pump

›Not applicable to HZO

›Anticoagulation and fibrinolysis

›Anticoagulation

›Not routine for HZO

›Specialist-guided only if VZV vasculopathy or retinal vasculitis is identified

›Fibrinolysis

›HZO is an under-recognized risk factor for ipsilateral stroke from VZV vasculopathy in the following months

›Standard fibrinolysis eligibility criteria still apply in a stroke work-up; antiviral therapy is a secondary consideration and does not replace the acute stroke pathway

›Analgesia

›Systemic analgesia

›Preferred over any topical ophthalmic approach

›Topical ophthalmic anesthetic

›Contraindicated for outpatient dispensing

›In-ED single use for examination only

09Special Populations/sp43

Pregnancy

›Pregnancy considerations

›Maternal HZO management priorities

›Vision preservation takes priority alongside fetal safety review

›Immediate ophthalmology involvement unchanged by pregnancy

›Antiviral safety

›Acyclovir and valacyclovir are generally considered acceptable in pregnancy when indicated

›Shared decision-making with obstetrics for IV therapy

›Topical ocular therapy

›Cycloplegic and IOP-lowering drop selection reviewed with ophthalmology

›Minimize systemic absorption with punctal occlusion technique

›Exposure counseling

›Avoid contact with non-immune pregnant contacts

›Cover lesions until crusted

Geriatric

›Older adult considerations

›Higher HZO incidence and higher postherpetic neuralgia risk

›Early antiviral initiation prioritized

›Early neuropathic analgesia consideration

›Renal function

›Renal dose adjustment required for all systemic antivirals

›Baseline creatinine before IV acyclovir

›Medication safety

›Avoid high anticholinergic burden agents such as amitriptyline when alternatives exist

›Beta-blocker eye drop systemic absorption risk with bradycardia or bronchospasm

›Chronic ocular complication risk

›Higher risk of recurrent or chronic keratouveitis

›Longer-term ophthalmology follow-up

10Background/b44

Epidemiology

›Disease burden

›Herpes zoster ophthalmicus accounts for approximately 10 to 20% of all herpes zoster cases

›Reactivation confined to the ophthalmic division of the trigeminal nerve

›Without antiviral therapy, ocular complications occur in approximately 50% of HZO cases

›Early oral antiviral therapy reduces this to approximately 20 to 30%

›Chronic or recurrent ocular inflammation can persist or recur months to years after the acute episode

›Recurrent keratitis and uveitis are the most common long-term problems

›Vaccination impact

›Recombinant zoster vaccine reduces overall zoster incidence including HZO

›Breakthrough cases still occur

›Stroke association

›Increased risk of subsequent ipsilateral stroke from VZV vasculopathy, greatest in the first 6 months after HZO

›Antiviral treatment associated with reduced risk in observational data

Pathophysiology

›Viral reactivation and anatomic basis

›Latency in the trigeminal ganglion with reactivation along the ophthalmic division

›Nasociliary branch shared innervation of the nose tip and the globe explains Hutchinson sign

›Anterograde spread along the sensory nerve to skin and ocular structures

›Ocular complication mechanisms

›Direct epithelial infection

›Pseudodendritic keratitis

›Immune-mediated stromal inflammation

›Stromal keratitis

›Anterior uveitis

›Trabecular meshwork inflammation

›Secondary glaucoma

›Occlusive retinal vasculitis

11Patient Discharge Instructions/pdi29

copy discharge instructions

›Discharge instructions

›Diagnosis explanation

›Shingles affecting the eye branch of the facial sensory nerve

›Can affect the eye even without prior eye symptoms

›Medications

›Antiviral medication exactly as prescribed for the full course

›Pain regimen schedule

›No eye drops other than what ophthalmology specifically prescribes

›Eye symptom monitoring at home

›Check vision in each eye separately once daily

›Watch for new eye pain, redness, light sensitivity, or blurred vision

›Skin care

›Keep the rash clean and dry

›Do not scratch vesicles

›Cover lesions until crusted

›Contagion precautions

›Avoid contact with anyone who has not had chickenpox or the chickenpox vaccine until lesions are fully crusted

›Avoid newborns

›Avoid pregnant individuals without confirmed prior chickenpox or vaccination

›Avoid immunocompromised contacts including transplant recipients and people on chemotherapy

›Return to emergency care

›Any new or worsening eye pain, redness, or vision change

›New floaters or flashes of light

›Severe headache, confusion, or new weakness

›Fever or rapidly spreading redness

›Pain not controlled with the prescribed plan

›Follow-up

12References/r19

Guidelines and key sources

›Core references

›American Academy of Ophthalmology Preferred Practice Pattern guidance on herpes zoster ophthalmicus

›Urgent ophthalmology evaluation for Hutchinson sign or ocular symptoms

›Systemic antiviral therapy as standard of care

›CDC and ACIP shingles clinical and vaccination guidance

›Recombinant zoster vaccine recommendations

›Infection control and contagion counseling

›Cobo and colleagues oral acyclovir trial in acute herpes zoster ophthalmicus

›Landmark trial demonstrating reduced ocular complications with early oral antiviral therapy

›Zoster Eye Disease Study

›Randomized trial of prolonged suppressive valacyclovir after acute HZO

›Did not demonstrate a significant reduction in new or worsening ocular inflammation versus placebo

›Evidence tags for internal protocol use

›Strong consensus tag

›Early systemic antiviral therapy for herpes zoster ophthalmicus

›Ophthalmology-only initiation of topical corticosteroid therapy

›Expert consensus and specialist-guided tag

›IV antiviral escalation thresholds

›Acute retinal necrosis management pathway

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.