5.8 Herpes Zoster Ophthalmicus

eyes.nhs.scot/
Eyecare Guidelines/
Section 5 - Cornea/
5.8 Herpes Zoster Ophthalmicus

Date of last review:

19/12/2025

Date of next review:

19/12/2027

Date of publication:

19/1/2026

This is a GOS Specialist Supplementary condition and should be managed by community optometrists in line with national guidance⁽⁸⁾. This guideline should be read in conjunction with ‘Supporting information’ guidance [link to Supporting Information page]

Differential diagnosis ⁽¹⁾

Ocular
- Herpes simplex keratitis
Cutaneous
- Cellulitis
- Contact dermatitis
- Atopic eczema
- Impetigo

Possible management by optometrist

Advice

Advise rest, hydration, and supportive care ⁽¹⁾
Avoid contact with:⁽¹⁾
- Elderly
- Pregnant individuals
- Children not exposed to Varicella Zoster Virus (VZV)
- Immunocompromised patients
Ocular complications: Exclude posterior uveitis and retinal necrosis (post-dilation) ⁽¹⁾
HZO can result in moderate-to-severe loss of vision in a significant proportion of patients with ocular involvement, even with timely and appropriate management ⁽¹⁾
- Ocular lesions may occur early or develop within one month after the onset of the skin rash and therefore patients may need to be monitored even after the rash starts to improve ⁽¹⁾
Be aware of the potential complications of HZO (shingles) infection ⁽⁷⁾
- Complications | Background information | Shingles | CKS | NICE

Treatment

Ocular lubricants for symptomatic relief as required (drops/gel for use during the day ± unmedicated ointment for use at bedtime)⁽¹⁾. Refer to local formularies for suitable options⁽⁶⁾
Recommend simple over the counter pain relief with advice from pharmacist if needed or stronger analgesics (co-managed with GP)^(1,7)
- ‘Seek specialist advice if pain is inadequately controlled by oral analgesia’ Management | Shingles | CKS | NICE
Early treatment (optimal ⁽⁷⁾ within 72 hours of rash onset) with oral antivirals (e.g. aciclovir);⁽¹⁾
- Reduces the likelihood of eye disorders and lessens acute pain ⁽¹⁾
- ‘If it is not possible to initiate treatment within 72 hours, consider starting oral antiviral treatment up to one week after rash onset especially if the person is at higher risk of severe shingles or complications’ Management | Anti Viral treatment | Shingles | CKS | NICE

Practitioners should consult “Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/ ⁽⁸⁾when managing HZO under GOS Specialist Supplementary ⁽⁷⁾.

Some Health Boards may have local protocols allowing for community-based management (outwith GOS Specialist Supplementary); these can be found in the clinical and referral protocols section of each Board’s page on eyes.nhs.scot ⁽⁷⁾.

In cases where the above circumstances do not apply ^(7);

The College of Optometrists advises that suspected cases should be referred urgently (same day) to the GP for systemic antiviral treatment⁽¹⁾.

Typical adult dosage/duration

(Blue text = IP, black text = non-IP)

Oral Aciclovir tablets ^(1,5) (POM): 800mg five times daily for 7 days (ensure adequate hydration especially in the elderly and those with impaired renal function ⁽³⁾)
Oral Valaciclovir tablets ^(1,5) (where Aciclovir contraindicated) (POM): 1g 3 times daily for 7 days ^(3,4)
- Caution is advised when administering valaciclovir to patients with impaired renal function. Adequate hydration should be maintained ^(3,4)

Regimens should be adjusted according to severity and patient factors (e.g. age, weight, pregnancy, renal function). Prescribing should follow local formulary and local/national guidance where available ⁽⁷⁾.

In cases of known sensitivities, please consult local formularies for alternative options ⁽⁷⁾

Further management options

Due to the systemic nature of herpes zoster it is prudent to inform the GP of the diagnosis and treatment and to include them in management of the condition particularly around the risk of chronic neuropathic pain following resolution of active infection and other sequelae such as skin lesions ⁽⁷⁾
GOS Specialist Supplementary Stage 1 to assess and establish likely presence of HZO* ⁽⁸⁾
- If keratitis is mild and limited to epithelium may consider co-management with GP; requires close monitoring due to risk of chronic complications. Maintain low threshold for referral since HZO is associated with chronic and recurrent complications that may be sight threatening ⁽¹⁾
- Same-day intra-referral to GOS Specialist Supplementary Stage 2* (or GP if appropriate) for systemic antivirals if required ⁽⁸⁾ (see note above regarding systemic antiviral treatment)
Urgent referral to Ophthalmology ⁽¹⁾if:
- Deeper corneal involvement
- Disciform keratitis
- Neurotrophic ulceration
- Uveitis (anterior/posterior)
  - Anterior uveitis may be managed under GOS Specialist Supplementary where appropriate ⁽⁷⁾
- Significantly raised IOP
GOS Specialist Supplementary Stage 2* treatment should be provided by a local IP optometrist/OMP who is registered and qualified to carry out GOS Specialist Supplementary Stage 2 management; intra-referral (practice to practice) should take place to facilitate this ⁽⁸⁾
Treatment may be provided within available locally enhanced schemes, or by community IP optometrists/OMPs, as appropriate (outwith GOS Specialist Supplementary) ⁽⁷⁾

*Treatment should be provided in line with “Annex C of the Statement” ⁽⁸⁾https://www.eyes.nhs.scot/for-professionals/legislation/

Possible management in secondary care or local/community pathways where available ^(1,8)

See Further management options
Systemic antivirals: aciclovir, famciclovir, valaciclovir
Topical antivirals (off-licence)
Topical steroids
Immunosuppressive therapy (e.g. for scleritis)
Surgical options for neurotrophic ulcers (e.g. tarsorrhaphy)
Treat associated ocular complications

College of Optometrists Clinical Management Guideline⁽¹⁾

Herpes zoster ophthalmicus (HZO) - College of Optometrists *

*With special thanks to The College of Optometrists for providing the evidence framework for diagnosis and management from the Clinical Management Guidelines (CMGs) for this condition. All references to the College/CMGs are included where appropriate and form the basis of the Community Eyecare Guidelines.

Guidance is informed by the following sources

College of Optometrists Clinical Management Guidelines Clinical Management Guidelines - College of Optometrists
Advisory alignment with the College of Optometrists Formulary Optometrists' Formulary - College of Optometrists
Advisory alignment with the BNF BNF (British National Formulary) | NICE
Advisory alignment with the Summary Product Characteristics taken from the EMC Home - electronic medicines compendium (emc)
Advisory alignment with Scottish Health Board formularies (where a clear majority is present) *
Advisory alignment with expert consensus (CEGG), informed by sources 2-5 above
Advisory alignment with expert consensus (CEGG)
“Annex C of the Statement” https://www.eyes.nhs.scot/for-professionals/legislation/

* Scottish formularies should be available within the Prescribing section of your Health Board pages on the eyes.nhs.scot website. If unavailable, contact your local Health Board for further information; Health Boards landing page

If you have a query relating to this page, please email NSS.ComEyecareGuidelineGroup@nhs.scot

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