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Practice 10-Minute Consultation

Herpes zoster ophthalmicus

BMJ 2019; 364 doi: (Published 17 January 2019) Cite this as: BMJ 2019;364:k5234
  1. Darren Shu Jeng Ting, clinical research fellow in ophthalmology1 2,
  2. Niru Ghosh, consultant general physician3,
  3. Saurabh Ghosh, consultant ophthalmologist1
  1. 1Sunderland Eye Infirmary, Sunderland, UK
  2. 2Academic Ophthalmology, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
  3. 3Mayfield Medical Group, Jarrow, UK
  1. Correspondence to Darren Shu Jeng Ting ting.darren{at}
  • Accepted 2 November 2018

What you need to know

  • Offer patients systemic antiviral medication to reduce complications, notably corneal complications and potentially post-herpetic neuralgia

  • Herpes zoster ophthalmicus may directly involve the eye and/or the skin around the eye, or may occur without ocular involvement, where only the skin of the V1 dermatomal region is affected

  • Refer to ophthalmology if a patient has ocular symptoms or signs

A 70 year old man attended with a two day history of painful vesicular rash affecting the left forehead accompanied by a red, painful left eye. Three days before the onset of the rash, he had experienced a tingling sensation at the left forehead. A clinical diagnosis of herpes zoster ophthalmicus with ocular involvement was made.

Herpes zoster, or shingles, is a common infection caused by the reactivation of varicella zoster virus that lies dormant in the dorsal root nerve ganglion following primary chickenpox infection. Herpes zoster ophthalmicus accounts for 10-20% of cases of herpes zoster infection.1 Patients usually present with painful, vesicular, dermatomal rashes affecting the ophthalmic division of the trigeminal nerve (V1). The diagnosis is usually made on clinical grounds but a viral swab can confirm the diagnosis.

Herpes zoster ophthalmicus may present with ocular involvement such as conjunctivitis, keratitis, iritis, and uveitis. It can also present without ocular involvement (where only the skin of the V1 dermatomal region is affected). Herpes zoster infection may rarely present without any cutaneous manifestation, also known as “zoster sine herpete,” with or without ocular involvement, rendering the diagnosis more difficult.2

This article aims to discuss the key points to cover in a history, examination, and initial management plan for a person attending primary care with a likely diagnosis of herpes zoster ophthalmicus.

What you should cover


Presenting complaint

When did the rash start? Starting oral antiviral treatment within 72 hours of the onset of rash substantially reduces …

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