Herpes Zoster Ophthalmicus: Hutchinson Sign, Antivirals and Eye Complications
Last updated: November 2026
Herpes zoster ophthalmicus (HZO) is shingles in the ophthalmic division of the trigeminal nerve. Eye involvement can appear with the rash or months later, so every patient needs early antivirals and an eye examination.
Recognise it
- A painful vesicular rash in the V1 dermatome (forehead, upper lid, nose) that respects the midline, often after a prodrome of pain or tingling.
- Hutchinson sign: lesions on the tip, side or root of the nose (nasociliary branch) mean a high risk of eye involvement.
- Risk factors: age over 50, immunosuppression; consider HIV testing in young patients.
Antivirals: start early
| Drug | Adult dose |
|---|---|
| Valaciclovir | 1 g three times daily for 7 days |
| Famciclovir | 500 mg three times daily for 7 days |
| Aciclovir | 800 mg five times daily for 7 days |
Start within 72 hours of the rash if possible, but still treat later if new lesions are appearing or the eye is involved. Adjust doses for kidney function. IV aciclovir for immunocompromised patients, orbital or neurological involvement.
Eye complications
| Structure | Complication | Management |
|---|---|---|
| Lids | Scarring, ptosis, lid retraction, trichiasis | Lubricants; lid surgery later |
| Conjunctiva | Follicular conjunctivitis | Lubricants |
| Cornea | Pseudodendrites (no terminal bulbs), nummular stromal keratitis, disciform keratitis, neurotrophic keratopathy | Topical steroid for stromal keratitis under antiviral cover; lubricants, punctal plugs and tarsorrhaphy for neurotrophic ulcers |
| Uvea | Anterior uveitis, sectoral iris atrophy, raised IOP (trabeculitis) | Topical steroid, cycloplegic, IOP control |
| Retina and nerve | Acute retinal necrosis, optic neuritis, cranial nerve palsies (especially III) | Urgent specialist care, IV antivirals |
Afterwards
- Follow up eye involvement closely and taper steroids slowly: stromal disease relapses.
- Postherpetic neuralgia: early pain control and referral.
- Recombinant zoster vaccine (two doses) is recommended for adults over 50 and immunocompromised adults; it is not a treatment for active disease.
Where residents slip
- Waiting for eye signs before starting antivirals.
- Calling a zoster pseudodendrite a herpes simplex dendrite.
- Stopping steroids abruptly in zoster stromal keratitis.
- Missing raised IOP from trabeculitis.
Test yourself: flip cards
Related: Dendrites & Pseudo-dendrites, Microbial Keratitis: A Workup Approach, Uveitis Made Easy: SUN Terms, Patterns and Work-up.
Key sources
- Minor M, Payne E. Herpes zoster ophthalmicus. CMAJ. 2018;190:E656 (practice summary)
- Cohen EJ, et al. Zoster Eye Disease Study (ZEDS) protocol. Cornea. 2020
- Lal H, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015;372:2087-2096
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