Herpes Eye Infections



  • Eye infection (blepharitis, conjunctivitis, keratitis, stromal keratitis, uveitis, retinitis, glaucoma, or optic neuritis) caused by herpes simplex virus (HSV) types 1 or 2 or varicella-zoster virus (VZV, also known as human herpes virus type 3 [HHV3])
    • HSV: most often affects the cornea (herpes keratoconjunctivitis); HSV1 > HSV2; can be further divided into primary and recurrent
    • VZV: When VZV is reactivated and affects the ophthalmic division of the 5th cranial nerve, this is known as herpes zoster ophthalmicus (HZO)—a type of shingles.
  • System(s) affected: eye, skin, central nervous system (CNS) (neonatal)


Predominant age: HSV—mean age of onset 37.4 years but can occur at any age, including primary infection in newborns; VZV—usually advancing age (>50 years)


  • HSV keratitis: In Europe, North America, and South America, approximated at 12.5 to 31.5 new or recurrent cases per 100,000 person-years (1)
  • VZV: 1 million new cases of shingles per year in the United States; 25–40% develop ophthalmic complications. Temporary keratitis is most common.

VZV: Prevalence of herpes zoster infection is 20–30%. Ocular involvement in 50% if not treated with antivirals; overall lifetime prevalence of HZO: 1%

Etiology and Pathophysiology

  • HSV and VZV are herpesviridae dsDNA viruses.
  • HSV: primary infection from direct contact with infected person via saliva, genital contact, or birth canal exposure (neonates)
    • Primary infection may lead to severe disease in neonates, including eye, skin, CNS, and disseminated disease.
    • Recurrent infection is more common overall cause of herpetic eye infections.
  • VZV: Primary infection from direct contact with infected person may cause varicella (“chickenpox”) and/or lead to a latent state within trigeminal ganglia.
    • Reactivation of the virus may affect any dermatome (resulting in herpes zoster or “shingles”), including the ophthalmic branch (HZO).

Risk Factors

  • HSV: personal history of HSV or close contact with HSV-infected person
    • General risk factors for reactivation: stress, trauma, fever, UV light exposure, other viral infections
    • Risk factors for HSV keratitis: UV laser eye treatment, some topical ocular medications such as prostaglandin analogues, and primary/secondary immunosuppression
  • HZO
    • History of varicella infection, advancing age (>50 years), sex (female > male), acute/painful prodrome, trauma, stress, immunosuppression (2)
Consider primary/secondary immunodeficiency disorders in all zoster patients <40 years of age (e.g., AIDS, malignancy).

General Prevention

  • Contact precautions with active lesions (HSV and VZV)
  • VZV can be spread to those who have not had chickenpox, are not immunized, or are not immune.
  • Varicella recombinant zoster vaccine (Shingrix) (VZV only): 2 doses 2 to 6 months apart recommended by the CDC for all persons aged ≥ 50 years
    • Do not give varicella vaccine during an acute infection.
  • Acyclovir can be used prophylactically to prevent recurrence of ocular HSV.

Pregnancy Considerations

  • Pregnant women without history of chickenpox should avoid contact with persons with active zoster.
  • Pregnancy increases risk of recurrence of HSV/VZV.
  • Shingrix is contraindicated during pregnancy.

Commonly Associated Conditions

Primary and secondary immunocompromised states

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