Shingles of the Eye

Shingles of the eye almost always affects ONE side of the face. The hallmark is the rash, but pain often comes first. Common symptoms include:

• Burning, tingling, or pain on one side of the forehead, upper eyelid, or scalp — sometimes for 1-3 days before any rash.
• A painful blistering rash in a band on one side of the forehead, upper eyelid, and scalp. The rash stops sharply at the middle of the forehead.
• Vesicles on the tip or side of the nose (Hutchinson sign). This means the same nerve branch that supplies the inside of the eye is involved, and the eye is at higher risk ³.
• Marked eyelid swelling on the affected side. The eye may be partly or fully closed.
• A red, watery eye on the same side, with light sensitivity.
• Blurry vision, eye pain, or a foreign-body feeling if the cornea is involved.
• Fever, headache, fatigue, and feeling generally unwell.

Less commonly, shingles can cause double vision (from cranial nerve involvement), facial muscle weakness, or hearing loss.

Shingles is caused by the same virus that causes chickenpox — varicella-zoster virus (VZV). After a chickenpox infection, the virus stays dormant in the nerve cells along the spinal cord and brainstem for life. Years later, often when the immune system is weaker, the virus can reactivate and travel back along a nerve to the skin. When it travels along the V1 (ophthalmic) branch of the trigeminal nerve, the result is herpes zoster ophthalmicus — shingles of the eye ¹.

Who is at higher risk:

• Adults over 50. Risk rises with each decade of life.
• People with weakened immune systems — cancer treatment, organ transplant medications, HIV, or long-term steroid use.
• People who have not had the recombinant zoster vaccine.
• People under heavy emotional or physical stress, or sleeping poorly.
• Anyone who has had chickenpox before. About 1 in 3 people will get shingles in their lifetime if not vaccinated.

Shingles itself is not contagious as shingles, but the fluid in the blisters can give chickenpox to someone who has never had it. People with active shingles should keep the rash covered around pregnant women, newborns, and immunocompromised people until the rash is crusted.

Treatment has three goals: kill the virus, calm eye inflammation, and control pain.

Antiviral pills (the most important step):

• Oral acyclovir, valacyclovir, or famciclovir for 7 days, started within 72 hours of the rash appearing. Antivirals shorten the illness, lower the chance of eye complications of herpes zoster ophthalmicus, and may reduce the risk of postherpetic neuralgia ⁸.
• Antivirals can still help if started after 72 hours, especially if new lesions are forming or the eye is involved — see an eye doctor anyway.
• Long-term low-dose suppression. Some patients with recurrent eye disease take a low daily dose of valacyclovir for a year or longer to prevent recurrences. The Zoster Eye Disease Study examined this approach with low-dose valacyclovir ⁷.

Eye care:

• See an eye doctor early. A slit-lamp exam looks for keratitis, anterior uveitis, raised eye pressure, or scleritis. Many of these need topical steroid drops, glaucoma drops, or both.
• Lubricating drops for the surface dryness that often follows shingles eye disease.
• Long-term follow-up. Eye disease can flare months or years later.

Pain control:

• Acetaminophen, NSAIDs, or short courses of stronger pain medicine for the acute illness.
• For ongoing nerve pain (post-herpetic neuralgia), gabapentin, pregabalin, amitriptyline, topical lidocaine patches, or capsaicin cream.
• For severe or persistent pain, a pain specialist may be helpful. Vaccination after recovery also reduces recurrent shingles disease ⁶.

The recombinant zoster vaccine (Shingrix) is more than 90% effective at preventing shingles in healthy adults age 50 and older. It is given as two doses, 2-6 months apart. Real-world studies show the recombinant zoster vaccine also strongly reduces herpes zoster ophthalmicus specifically ⁴.

Who should get Shingrix?

• Healthy adults age 50 and older — even if they have already had shingles or had the older Zostavax vaccine.
• Adults age 19 and older who are or will be immunocompromised because of disease or treatment.
• People who have had herpes zoster ophthalmicus in the past, to lower the chance of recurrence ⁹.

What to expect: Sore arm, mild fever, fatigue, or muscle aches for 1-3 days are common after each dose, especially the second. These are signs the immune system is responding.

If you have already had shingles in the eye, talk to your doctor about timing — most experts recommend waiting until the active rash has healed before vaccinating, but the vaccine still helps prevent recurrent disease.