Early symptoms of Herpes zoster ophthalmicus

herpes eyesThe early symptoms of herpes zoster ophthalmicus (HZO) appear when the varicella-zoster virus reactivates in the ophthalmic branch of the trigeminal nerve (VI). When a person has had, say, chickenpox, the varicella-zoster virus remains dormant in the nerve tissue near the spinal cord and brain.

Herpes zoster is an acute, painful, vesicular eruption. Early symptoms of HZO may include:

  • Dysesthesias of the forehead and brow.
  • A vesicular rash that respects the midline can then develop on the forehead, brow, eyelids, and, at times, the conjunctiva.
  • Hutchinson sign (skin lesions at the tip, side, or root of the nose).
  • Erythematous skin lesions with macules, papules, vesicles, pustules, and crusting lesions.
  • Severe or mild rash that may be mistaken for acne.
  • A red eye on the involved side indicating ocular involvement.
  • Conjunctivitis.
  • Dendritic keratitis.
  • Uveitis.
  • Retinitis.
  • Fever.
  • Malaise.
  • Headache.
  • Eye pressure.
  • Eye redness.
  • Decreasing vision.
  • Eye pain before onset of rash.

More specifically, the signs depend also on the structure involved and the time onset of the rash – which is the main symptom.

Ocular and Cranial Nerve Involvement in Herpes Zoster Ophthalmicus



Time of onset





Cutaneous macular rash respecting midline and involving eyelids.

Day 0

Conjunctival edema/inflammation

2-3 days

Vesicular lesions/crusting

6 days





Diffuse or localized redness, pain, and swelling

1 week




Punctate epithelial keratitis

Swollen corneal surface epithelial cells

1-2 days

Dendritic keratitis

“Medusa-like” epithelial defect with tapered ends

4-6 days

Anterior stromal keratitis (nummular keratitis)

Multiple fine infiltrates immediately beneath corneal surface


Deep stromal keratitis

Deep stromal inflammation with lipid infiltrates and corneal neovascularization

1 month-years

Neurotrophic keratopathy

Punctate corneal surface erosions


In addition to having been previously infected with varicella-zoster, other risk factors for HZO include:

  • Being 60 of age or older.
  • Illness, trauma, stress, or immunosuppression (secondary to chemotherapy, HIV, radiation, malignancy, etc).
  • Severe acute zoster pain and rash.
  • A painful prodrome.
  • Ocular involvement.
  • Poor nutrition.
  • Race (elderly black patients are one fourth as likely as elderly white patients to develop herpes zoster).
  • Having HIV.

The vesicular rash usually heals in 2 to 6 weeks but even after the acute stage of HZO has healed there may be potential complications, such as:

  • A chronic inflammatory course with frequent exacerbations.
  • Progressive corneal scarring and neurotrophic keratoconjunctivitis.
  • Post herpetic neuralgia.
  • Cerebrovascular accidents.
  • Ptosis.
  • Lid scarring.
  • Ectropion.
  • Sclera, limbal, and corneal atrophy.
  • Permanent vision loss.

Chronic recurrent HZO (long after the rash has healed) can be very difficult to treat and may lead to corneal scarring and neovascularization. Thus, timely diagnosis is essential. Among the things that doctors look for in HZO is the blistering rash in the distribution of the ophthalmic branch of the trigeminal nerve. The rash will respect the midline following the course of V1. Patients with severe immunosuppression can experience multidermatomal rash. The vesicular rash may involve the eyelids and conjunctiva. Close inspection of the cornea may show a dendritic keratitis resembling that seen in HSV keratitis, except that the dendrites do not have the typical "terminal bulbs." A second type of dendritiform lesion called a "pseudodendrite" can be observed in HZO; a mucous plaque-like lesion in the shape of a dendrite on the epithelium of the cornea. HZO is also known to cause uveitis and iris transillumination defects in a sectoral pattern. Dilated fundus exam is very important in HZO as a necrotizing retinitis can seldom develop.

Recommended treatment for the early symptoms of herpes zoster ophthalmicus




  • Acyclovir 800 mg orally 5 times a day for 7-10 days.


  • Palliative with cool compresses, mechanical cleansing.


  • Palliative, with cool compresses and topical lubrication.
  • Topical broad-spectrum antibiotic indicated for secondary bacterial infection.

Epithelial keratitis

  • Debridement or none.

Stromal keratitis

  • Topical steroids

Neurotrophic keratitis

  • Topical lubrication.
  • Topical antibiotics for secondary infections. 
  • Tissue adhesives and protective contact lenses to prevent corneal perforation.


  • Topical steroids.
  • Oral steroids.
  • Oral acyclovir.


  • Topical nonsteroidal anti-inflammatory agents and/or steroids.

Acute retinal necrosis/progressive outer retinal necrosis

  • Intravenous acyclovir for 7-10 days, followed by oral acyclovir for 14 weeks.
  • Laser/surgical intervention.


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