Each year, about 100,000 of the 1 million people in the United States who get shingles will also develop ocular shingles. Also known as herpes zoster ophthalmicus (HZO), ocular shingles is a potentially serious and painful condition that affects the eye and surrounding skin.

We spoke to Nebraska Medicine ophthalmologist Brian Armstrong, MD, to help you understand ocular shingles and take action if you or someone you know is affected. 

What is ocular shingles and what causes it?

Shingles is caused by reactivation of the varicella-zoster virus, the same virus that causes chickenpox. The physical signs of chickenpox disappear as your immune system fights off the virus, but it always stays in your body. If the virus reactivates in the eye area, it causes ocular shingles. 

“For a variety of reasons, the shingles virus can reactivate and cause inflammation where the virus has been living dormant in the body,” says Dr. Armstrong. “If the virus is living in a nerve root ganglion that gives sensation to the eye, it causes ocular shingles.”

Ocular shingles follows nerve pathways and can cause severe pain and rashes on the eyelids, forehead and scalp. It often affects only one eye. 

“The virus is highly contagious, which is why most of us have been exposed,” says Dr. Armstrong. “However, ocular shingles isn’t contagious in the sense that you can catch it directly from someone who has it. Most people are already immune to the virus.”

Symptoms of ocular shingles

“Ocular shingles cause painful skin rashes, swelling around the eye, redness, tearing and decreased vision, in some cases,” says Dr. Armstrong.

A red, blistering rash typically appears on the forehead, eyelid or bridge of the nose. It can look similar to a typical shingles rash. The affected eye and surrounding skin may appear swollen and puffy. 

Other symptoms may include:

• Headache.
• Burning or throbbing eye pain.
• Persistent eye irritation.
• Skin tenderness.
• Blurred vision.
• Itching and tingling.
• Light sensitivity. 
• Mild flu-like symptoms.

These signs can appear days before the rash shows up. If you notice any, especially in the eye or forehead area, seek medical care immediately.

Who is at risk for ocular shingles? 

Anyone who had the chickenpox virus or received the varicella vaccine is at risk for ocular shingles, as the virus can reactivate. People over 50 are more likely to develop ocular shingles because the immune system weakens with age. However, younger people can still develop ocular shingles, especially if they have a weakened immune system due to:

• Cancer treatments like chemotherapy.
• HIV/AIDS. 
• Organ transplants.
• Previous case of shingles. 
• Chronic stress or trauma.
• Underlying health conditions such as diabetes or autoimmune disorders.
• Lack of chickenpox immunity.

How to reduce ocular shingles risk

While it’s not possible to prevent ocular shingles entirely, there are ways to lower your risk. The shingles vaccine is recommended for everyone over 50, even if they’ve had shingles before. Shingrix and Zostavax are effective treatments to reduce the risk of shingles, including ocular shingles. 

“We often advise everyone to get a shingles vaccination,” says Dr. Armstrong. “Even if someone had exposure to chickenpox or had the varicella vaccine, the immune system may forget how to attack the virus.” 

Dr. Armstrong emphasizes that maintaining a healthy lifestyle—through a balanced diet, adequate hydration and sleep, regular exercise and effective stress management—can significantly boost the immune system, improve overall health, keep the virus dormant and reduce the risk of shingles.

How to treat ocular shingles

Quick treatment can reduce the risk of ocular complications, including permanent vision loss. Treatment typically involves a combination of antiviral medications and pain management.

“Sometimes we recommend a long-term preventative antiviral treatment, especially for those who have frequent or severe outbreaks,” says Dr. Armstrong. “We use pain relievers and steroid tablets to prevent complications from the infection.”

If the virus moves to the eye itself, your doctor may prescribe antiviral or steroid eye drops. 

“Ocular shingles can cause scarring on the skin or cornea,” says Dr. Armstrong. “Scarring on the cornea may cause decreased vision. One of the most common things we see is a decreased sensation in the eye, which creates dryness and a risk for other types of infections.”

After treatment, regular follow-ups with an ophthalmologist are important to monitor for complications. 

“Ocular shingles can sometimes be misdiagnosed, which could lead to a delay in treatment,” says Dr. Armstrong. “When on the right treatment, however, recovery typically takes between 2 to 4 weeks.”