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Ophthalmic Shingles

Checked: 23-08-2020 by Vicky Ryan Next Review: 23-08-2021

Overview

Latent Herpes Zoster can reactivate from the ophthalmic division of the trigeminal nerve causing the classic rash around the scalp, forehead and eyelids. As the ophthalmic division also supplies the cornea with sensation it can cause inflammation within the eye.

Eye involvement in ophthalmic shingles is much more likely if the tip of the nose is involved (Hutchinson’s sign) as this indicates the nasociliary nerve is involved (which supplies the cornea and the tip of the nose).

Not all patients will develop inflammation in the eye following. Eye involvement can be varied including conjunctivitis, dry eye, corneal inflammation, iritis and retinal infection. The eye can be involved within a few days or weeks and months down the line. Once a patient has shingles, any eye complications in the following months should be treated as potential ophthalmic shingles.

Who to refer

NHS CKS recommends seeking specialist advice if there is herpes zoster ophthalmicus. Referral is particularly indicated for people with:

Red eye
Swollen Eyelids
Photophobia
Hutchinson’s positive (see above)
Reduced vision
Floaters
Immunocompromised
Pregnant

Red Flags

As above

Before referral

In the first 72 hours Aciclovir 800mg 5xday for 7 days should be commenced (see BNF). There is some benefit to initiating treatment for up to seven days following the start of shingles and this can reduce disease progression and postherpetic neuralgia. Patients do not need to wait for treatment prior to ophthalmology review.

Referral

Refer to BEH emergency department if there is active ophthalmic shingles (see red flags as above).

If a routine referral is required please submit to Ophthalmology via eRS requesting Cornea clinic.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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