Shingles in the Eye - Causes, Symptoms & Treatment

9 sources cited
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How Do You Get Shingles in the Eye?

Eye shingles, also called herpes zoster ophthalmicus (HZO) or ophthalmic herpes zoster, is a painful rash in or around the eye. It also occurs in other areas, such as the face, forehead, and scalp.1

You may get shingles in the eye if you’ve previously contracted chickenpox, and the virus that causes it (varicella-zoster virus) reactivates years later.2 Those vaccinated against chickenpox may also develop eye shingles later in life, although the risk is low.

Chickenpox is characterized by highly contagious fluid-filled blisters that spread all over the body and face. The symptoms last about 4 to 7 days.  

After you recover from chickenpox, the virus stays dormant in the nervous system. However, it may reactivate in the trigeminal nerve years later, causing shingles in the eyes. 

Ocular shingles are not contagious, but the virus can spread to another person who has never had chickenpox or been vaccinated against it. This can only happen if they come into contact with active blisters from another person. In this case, they will develop chickenpox and not shingles. 

Risk Factors

The CDC indicates that 1 in 3 people in the United States will develop herpes zoster (shingles) in their lifetime.3 Risk factors include:

  • Age (age 50 or older)
  • Prior case of chickenpox
  • Low immunity due to diseases like HIV or cancer
  • Depression
  • Certain medications, e.g., steroids and cancer medication

Can You Go Blind with Shingles?

Yes, shingles can cause blindness. Shingles may cause inflammation at the front or back of the eye (keratitis).4 

Shingles may also cause viral retinitis if the inflammation occurs at the back of the eyes (on the retina or optic nerve). Keratitis occurs in about 50% of all shingles cases, whereas viral retinitis is a less common complication.5

If shingles in the eye are left untreated, they may also cause increased intraocular pressure (IOP) pressure in the eyes (glaucoma). Keratitis, retinitis, and glaucoma can damage your eyes, ultimately causing permanent vision loss.

Early treatment of eye shingles using antiviral drugs will prevent or reduce the risk of complications that can cause blindness. 

Symptoms of Shingles in the Eye

Shingles in the eye often begin with a painful blistering rash on one side of the upper face, including the nose, forehead, or scalp. 

Research shows about 10 to 20% of shingles cases affect the eye.6 One indicator of eye shingles is a rash on the tip of your nose. Sometimes, ocular shingles may appear without a skin rash. 

Symptoms include:

  • A blistering rash around the eyes 
  • A painful and inflamed cornea (keratitis)
  • Itching 
  • Severe pain or burning sensation
  • Tingling sensations
  • Difficulty moving the eye (nerve palsy)

Other Symptoms of Shingles

The following symptoms may occur alongside the blistering rash:

  • Redness
  • Swelling
  • Headache
  • Sensitivity to light (photophobia)
  • Blurry vision
  • Tearing or watery eyes
  • Eye irritation
  • Dry eyes
  • Fever and chills
  • Nausea
  • Vision loss in severe cases
  • Double vision (rare)
  • Muscle weakness or paralysis (rare)

If you suspect you have eye shingles, seek medical attention as soon as you can to prevent progression and eye damage.

Eye Shingles Diagnosis and Treatment

Your doctor can diagnose shingles by observing the rash on your face or eyes. They might take a fluid sample from the blister to test for the varicella-zoster virus. 

Doctors will also examine the following parts for the presence of swelling, inflammation, or damage:

  • The cornea (clear front part of the eye)
  • Eye lens (structure behind the pupil that focuses light on the retina)
  • The retina (the light-sensitive part of the eye)
  • Other parts of your eye, including the eyelid, the optic nerve, etc.

Treatment

Treatment for eye shingles mainly involves antiviral medication and supportive care to manage symptoms. 

Your doctor may also suggest other therapies such as antibiotics, topical or systemic corticosteroids, and eye surgery on a selective basis.

Systemic Antiviral Agents

Systemic antivirals are recommended at least 72 hours after disease onset. The dosage may differ depending on age, the severity of illness, and health status. 

This treatment involves a 7 to 10-day course of antiviral medication. Examples include:

  • Acyclovir (Zovirax)
  • Valacyclovir (Valtrex)
  • Famciclovir (Famvir)
  • Foscarnet (Foscavir), for immunocompromised people with severe illness or acyclovir-resistance 

Topical Antibiotics

Antibiotics may be administered selectively based on the presence of secondary bacterial infection. A common antibiotic is erythromycin ophthalmic ointment.

Pain Killers

Over-the-counter medications such as acetaminophen, ibuprofen, and naproxen can help relieve any associated pain. 

These medications may also help you manage postherpetic neuralgia (PHN), a burning sensation experienced by some people after the rash and blisters disappear. 

Your doctor may also prescribe tricyclic antidepressants to deal with postherpetic neuralgia. They will start you on a low dosage, taken at bedtime, and increase it every 2 to 4 weeks

Examples of tricyclic antidepressants include:

  • Desipramine (Norpramin)
  • Amitriptyline (Elavil)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)

Corticosteroids

Commonly referred to as steroids, corticosteroids are prescribed to deal with inflammation. Both topical and systemic corticosteroids may be used under the supervision of an ophthalmologist to prevent adverse effects of the drugs. 

Studies have shown that oral corticosteroid prednisone, combined with acyclovir, can reduce the pain associated with eye shingles.7 Your doctor may recommend corticosteroids in case of severe complications like keratitis, trabeculitis, or uveitis. 

Topical Aqueous Suppressants

These medications are used with topical corticosteroids to treat elevated intraocular pressure (IOP), a secondary symptom of eye shingles. In some cases, the steroid itself can increase IOP.

Topical aqueous suppressants decrease the production of the aqueous fluid and liquid flow into the eyes. Examples include:

  • Timolol (e.g., Timoptic XE Ocumeter® and Timoptic®) 
  • Levobunolol (Betagan®)

Debridement

Debridement is the surgical removal of dead tissues. To restore visual acuity, your ophthalmologist may consider debridement in cases of severe tissue damage, e.g., corneal scarring.

Supportive Care

Supportive care involves symptom management during recovery. Cold compresses, artificial tears, and painkillers may be considered in this case. 

Cold compresses help relieve symptoms such as swelling and pain, while artificial tears prevent discomfort caused by eye shingles.

According to the CDC, calamine lotion and colloidal oatmeal baths (a lukewarm bath mixed with oatmeal grounds) can relieve itching.​​​​​​​8

Complications of Shingles in the Eye

Shingles of the eye pose a danger to your sight if left to progress. Dangerous complications include:

  • Eye damage such as scarring of the cornea
  • Postherpetic neuralgia, when damaged nerve fibers send inaccurate messages of pain to your brain
  • Neurological problems, such as brain inflammation (encephalitis), facial paralysis, and problems with hearing or balance
  • Bacterial skin infections 
  • Glaucoma or increased eye pressure that may damage the optic nerve
  • Cataracts (cloudy eye lens)
  • Pneumonia
  • Corneal ulcers
  • Double vision (diplopia)
  • Vasculopathy and stroke
  • Bleeding eyes, e.g., after debridement
  • High blood pressure as a complication of corticosteroids
  • Vision loss in case of severe eye damage
  • Death (very rare)

Shingles can severely affect pregnant women, premature infants, and immunocompromised people. The sooner you begin treatment, the lower your risk of complications. 

How Do You Prevent Eye Shingles?

The Food and Drug Administration (FDA) has approved Shingrix, a newer, more effective shingles vaccine.9 

According to the CDC, the vaccine is about 90% effective at preventing shingles and lowering the risk of severe illness. 

Shingrix is recommended for adults aged 50 years or older and younger adults (18 years or older) with a weak immune system. 

You can prevent shingles infection from spreading by: 

  • Staying away from older adults, pregnant women, and anyone who is immunocompromised
  • Not scratching or touching the rash, as this may escalate the infection
  • Covering the rash to avoid shedding
  • Cleaning your hands after touching the affected area

Summary

  • If you've contracted chickenpox before, you could get shingles in the eye, and the virus that causes it (varicella-zoster virus) reactivates years later. 
  • Common symptoms include a blistering rash around the eyes, sensitivity to touch, itching, pain or burning sensations, tingling sensations, swelling, fever, redness, and more.
  • Complications of shingles may include eye infections, eye damage, postherpetic neuralgia, glaucoma, or vision loss.
  • Your doctor can diagnose eye shingles by observing the rash on your eyelids and other eye parts. A lab test for the varicella-zoster virus is also possible.
  • The main treatment for eye shingles is systemic antiviral medications. However, topical antibiotics, corticosteroids, and painkillers may be prescribed to manage symptoms and complications.
  • Fortunately, young and older adults can be vaccinated as a preventive measure against shingles in the eye.
9 Cited Research Articles
  1. CDC. “Chickenpox (Varicella),” www.cdc.gov, 2021.
  2. Harvard Medical School. “Shingles of the eye can cause lasting vision impairment,” www.health.harvard.edu, 2021.
  3. CDC. “Shingles (Herpes Zoster),” www.cdc.gov, 2022.
  4.  American Academy of Ophthalmology, “Herpes Zoster Ophthalmicus,” www.aao.org. 
  5. National Center for Biotechnology Information (NCBI)“Herpes Zoster Ophthalmicus,” www.ncbi.nlm.nih.gov, 2021.
  6. Opstelten and Zaal. “Managing ophthalmic herpes zoster in primary care,” National Center for Biotechnology Information (NCBI), 2005.
  7. Whitley, Weiss et al. “Acyclovir with and without prednisone for the treatment of herpes zoster. A randomized, placebo-controlled trial,” American College of Physicians, 1996.
  8. CDC. “Treating Shingles,” www.cdc.gov, 2020.
  9. Food and Drug Administration (FDA). “Shingrix,” www.fda.gov, 2021.
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