Shingles-Related Glaucoma (Herpes Zoster Ophthalmicus)
Shingles affecting the eye and forehead (herpes zoster ophthalmicus) can cause severe, prolonged inflammation and glaucoma that often lasts longer and scars more than glaucoma from herpes simplex virus.
Overview
Herpes zoster ophthalmicus occurs when the varicella-zoster virus (the virus that causes chickenpox and shingles) reactivates in the nerve that supplies sensation to the forehead, eyelid, and eye. When the eye itself becomes involved, the resulting inflammation can cause trabeculitis (inflammation of the drainage tissue) and elevated eye pressure, similar in principle to herpetic (HSV) glaucoma but often more severe and long-lasting.
Symptoms
- A painful, blistering rash along the forehead, upper eyelid, and tip of the nose on one side
- Eye redness, pain, and light sensitivity
- Blurred vision
- In rare cases, eye involvement with little or no visible rash (zoster sine herpete)
How Common Is It?
Roughly 1 in 3 people will develop shingles in their lifetime, and about 10–20% of shingles cases involve the ophthalmic (eye-related) nerve branch, known as herpes zoster ophthalmicus.
Among patients with herpes zoster ophthalmicus, a meaningful subset — commonly cited around 10% — go on to develop elevated eye pressure or glaucoma, and the eye disease can be more severe and more likely to leave lasting scarring than herpes simplex-related eye disease.
Genetics & Risk Factors
Risk rises steadily with age, particularly after 50, and with any condition or medication that suppresses the immune system, since these reduce the body's ability to keep the dormant virus in check.
The shingles vaccine substantially reduces the risk of an outbreak, including the ophthalmic form, and is an important prevention discussion to have with your primary care physician if you're an eligible adult.
Ocular Findings on Exam
A distinctive finding is sectoral iris atrophy: patchy, wedge-shaped thinning of the iris that follows the distribution of the affected nerve, generally more full-thickness and more clearly patterned than the milder, patchier transillumination defects seen in herpes simplex-related disease.
The cornea may show pseudodendrites — branching lesions that resemble true herpes simplex dendrites but typically taper to a point without the swollen terminal bulbs seen in HSV, and tend to stain less avidly with fluorescein.
As with herpetic (HSV) glaucoma, the eye can show disproportionately high pressure relative to a relatively mild degree of visible inflammation.
Testing & Diagnosis
- Clinical diagnosis based on the classic dermatomal rash and pattern of eye involvement
- Slit-lamp exam for pseudodendrites and sectoral iris atrophy
- IOP measurement, which can be markedly elevated during active inflammation
- PCR testing of vesicle fluid or ocular fluid in atypical presentations without a clear rash
- Gonioscopy and optic nerve imaging once the acute episode has settled
Treatment Options
Prompt Antiviral Therapy
Oral antivirals (such as valacyclovir or famciclovir), started as early as possible after the rash appears, reduce the severity and duration of the illness and its eye complications.
Careful Steroid Use
Topical steroids are used to control eye inflammation, tapered thoughtfully with close pressure monitoring, since steroids can further raise eye pressure on top of the trabeculitis.
Eye Pressure Control
IOP-lowering drops are used during flares, and may be needed for a more prolonged period than in herpes simplex-related glaucoma given the tendency toward longer-lasting inflammation.
Long-Term Follow-Up
Because inflammation and pressure elevation can persist or recur for months to years after the rash heals, longer-term monitoring is typically recommended compared to other causes of viral uveitic glaucoma.
How This Differs From Other Glaucomas
Compared to herpes simplex (HSV) glaucoma, shingles-related glaucoma tends to be more severe, more prolonged, and more likely to leave permanent iris and corneal scarring, and the sectoral, nerve-distribution pattern of iris atrophy is a distinguishing exam clue between the two related conditions.
Prevention is also uniquely relevant here: because a vaccine exists to reduce the risk of shingles itself, discussing vaccination status is a meaningful part of care for this condition in a way that doesn't apply to most other glaucomas on this page.
Frequently Asked Questions
How is this different from herpetic (HSV) glaucoma?
Both are caused by related herpesviruses, but herpes zoster ophthalmicus (shingles) tends to cause more severe, more prolonged inflammation and iris damage, and often requires longer treatment than glaucoma from herpes simplex virus.
Can the shingles vaccine help?
Yes. The shingles vaccine reduces the likelihood of developing shingles at all, including the form that affects the eye, and is recommended for eligible adults — ask your primary care doctor if you're a candidate.
Will the rash always be visible?
Usually, yes — a blistering rash along the forehead, eyelid, and tip of the nose (following the affected nerve's distribution) is typical, though in rare cases eye involvement can occur with minimal or no visible rash.
How long does treatment usually last?
Inflammation and elevated eye pressure from shingles can persist or recur for months, and occasionally years, after the rash itself has healed, so longer-term follow-up is common compared to other causes of uveitic glaucoma.
See a glaucoma specialist. Dr. Robert Gunzenhauser is Harvard-educated and UCLA fellowship-trained in glaucoma, providing expert diagnosis and treatment for Shingles-Related Glaucoma at Inland Glaucoma Center in Upland, CA.