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Eye shingles: Causes, symptoms, treatments

Closeup of a man with eye shingles

You may think of shingles as a painful red rash on the body that causes weeks (typically 3-5 weeks) of misery before it resolves, but shingles also can strike the eye and cause lasting damage to your vision.

Over the past six decades, cases of shingles have been on the rise.

The number of ocular shingles (shingles in the eye) cases in the United States has tripled from 2004 to 2016, according to Kellogg Eye Center research presented at the 2019 Association of Vision and Ophthalmology meeting.

Researchers found that people over age 75 have the greatest risk. Whites and women also present with a higher incidence of ocular shingles.

What explains this increase? Weakening of the immune system from chronic diseases and stress are factors.

Dr. Christopher Rapuano, MD, chief of Cornea Service at Wills Eye Hospital, one of the top U.S. ophthalmic specialty hospitals, says few people are getting vaccinated for shingles, which is the best way to avoid the disease – and protect your eyes.

“Shingles can cause bad things to happen to the eyes, and some of those things can happen even with good treatment,” he says.

What causes shingles?

Before we take a closer look at shingles affecting the eye (herpes zoster ophthalmicus), let’s talk about what causes shingles in the first place: the chickenpox virus.

As an adult, you may have a hazy memory of spending a week in bed, your itchy body dotted in pink calamine lotion as you binged on daytime TV and ate ice lollies by the box.

The blisters may be long gone, but the chickenpox virus still lies dormant in your body.

About one in three U.S. adults will get shingles when the varicella-zoster virus that sparked their childhood chickenpox reactivates in the body.

Shingles typically starts out as a band of tenderness or tingling on your skin and then turns into a painful rash.

“People will tell you, ‘It was the worst pain I ever had,’” Rapuano says.

Can you get shingles in the eye?

It’s most common to get the shingles rash on your chest, back or legs but you can get shingles on the face and eye, Rapuano says. About 15% of cases involve shingles in the eye area, he says.

However, there’s a difference between having shingles around the eye and having shingles in the eye, which opticians refer to as “eye involvement,” Rapuano says. A patient can have shingles around the eye area without the eye itself being involved, he says.

About half of people who have shingles on the forehead or nose will also have eye involvement.

Ocular shingles typically occurs in one eye on the same side of the face as the rash. It typically occur after the shingles rash on the body has resolved, Rapuano says.

A patient who has had shingles on the face may feel like they’re healing well but then notice a symptom such as redness in the eye. When this happens, patients “need to see an optician right away,” Rapuano says.

Symptoms of shingles in the eye

The symptoms of shingles around the eye may be different from the symptoms of eye involvement. Symptoms of shingles around the eye area may include:

  • Tingling on the face

  • Blisters or rash on forehead or nose

  • Swollen eyelid 

Symptoms that may indicate eye involvement in shingles:

Patients who have shingles on the face should get antiviral treatment for shingles and also see an optician right away to monitor for ocular shingles.

Because the eye can become involved later in the disease process, it is important to follow up with the optician even if your eye appears fine at first.

Treatments for ocular shingles

The treatment for shingles around the eye is the same as treatment for shingles on any other area of the body. Three antiviral drugs (acyclovir, valacyclovir and famiciclovi) have been approved for treatment of shingles.

These drugs can:

  • Shorten the length of a shingles outbreak.

  • Make shingles less painful.

  • Reduce the chances of post-herpetic neuralgia, a complication that can cause ongoing pain and sensitivity after the rash resolves. 

In addition to these overall benefits, prompt treatment with antiviral medication can cut in half the incidence of eye disorders in ocular shingles.

Without antiviral medication, 50% of ocular shingles patients will develop eye disorders compared with only 25% of patients who take the medication.

It’s crucial to begin taking antiviral medication within 72 hours of the outbreak of the skin rash. “It should be started as soon as possible after the rash starts,” Rapuano says.

Treatments for shingles in the eye

There are a variety of different treatments for shingles in the eye. If your optician diagnoses eye involvement, you may also need topical eye drops. There are two main types of topical eye drops for shingles:

  • Corticosteroid eye drops – Steroid drops can reduce the eye inflammation caused by shingles, Rapuano says. This lowers the chances of complications from shingles of the eye.

  • Pupil-dilating eye drops – Your optician also may prescribe eye drops to keep the pupils open for pain relief due to an internal ocular inflammation caused by shingles.

Recovery from eye shingles

Recovery time varies by patient and the specific case, Rapuano says. “If the inflammation is mild and the treatment is pretty aggressive, then symptoms may start getting better within days,” he says.

At some point, the optician may try to slowly wean the patient off steroids. But a recurrence of inflammation may signal a need to keep using steroid eye drops.

“Many patients will need to be on low-dose steroids for years, if not forever,” Rapuano says.

Can eye shingles cause blindness?

Even with proper treatment, some eye shingles patients still develop eye disorders such as corneal scarring, glaucoma and retinal disease.

For example, eye shingles can cause:

  • A corneal dendrite which may lead to a scar

  • Uveitis (an internal inflammation of the eye)

  • Glaucoma (due to uncontrolled uveitis)

  • Blindness (in extreme cases)

In the most severe cases of eye shingles, a patient may need a corneal transplant.

Now that you’re aware of the dangers of ocular shingles, you may wonder whether ocular shingles (like chickenpox) is contagious. Ocular shingles is not contagious; it cannot be spread to another person.

However, a person who has shingles anywhere on the body (a rash) can transmit the chickenpox virus to someone who hasn't had chickenpox or been vaccinated against it.

Preventing shingles in the eye

When it comes to shingles – and especially ocular shingles – prevention is the best medicine.

Fortunately, there are two shingles vaccines:

  • Shingrix – A fairly new vaccine, Shingrix is recommended for adults ages 50 and up. You get Shingrix in two doses two to six months apart, and it’s more than 90% effective in protecting you from shingles and post-herpetic neuralgia. Protection stays strong for at least four years after you get vaccinated.

  • Zostavax – An older vaccine for shingles, Zostavax is a live vaccine that is less effective but may be used in healthy adults ages 60 and up if there’s a reason they can’t have Shingrix administered. For example, someone who is allergic to a component of Shingrix may opt for Zostavax.

The availability of a newer, more effective vaccine should prevent even more shingles outbreaks. “We recommend the vaccine for all of our patients,” Dr. Rapuano says.

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