Cornea
Herpes Zoster Keratitis
Also known as: HZO keratitis, VZV keratitis, zoster keratitis, zoster keratouveitis, pseudodendritic ulcer, nummular keratitis, shingles keratitis, HZO corneal involvement
Filed as: Urgent
Source-cited from the record's own evidence list. Clinical content programme led by Dr Ankit Mathur, PhD, Grad Cert Ocu Thera, B.S. Optom. How the clinical content is governed
Clinical decision support only
Overview
The cornea-specific manifestation of herpes zoster ophthalmicus (HZO), the broader V1 varicella-zoster reactivation syndrome. This record is for corneal disease: punctate epithelial keratitis, pseudodendrites, nummular keratitis, stromal/disciform keratitis, reduced corneal sensation, and neurotrophic keratopathy. Use the separate herpes zoster ophthalmicus record for periocular V1 shingles without current corneal involvement.
Recognition
Symptoms: what patients report
- Prodromal: severe unilateral forehead/periorbital pain or tingling — preceding the rash by 2–4 days.
- Unilateral dermatomal vesicular rash on the forehead and periorbital skin (V1 distribution).
- Eye pain, photophobia, and watering.
- Redness.
- Blurred vision.
- Lid swelling (ptosis), lid vesicles.
- Post-herpetic neuralgia: persistent severe burning pain after the rash heals.
Signs: what the examination shows
- Hutchinson's sign: vesicles on the tip of the nose (nasociliary branch involvement) — strongly predicts ocular involvement.
- Lid vesicles and lid oedema on the affected side.
- Pseudodendritic ulcer: raised mucus plaque with tapered ends (NO terminal bulbs, unlike HSV dendrites) — stains with rose bengal.
- Punctate epithelial erosions in the early phase.
- Anterior stromal (nummular) keratitis: coin-shaped subepithelial infiltrates.
- Disciform keratitis: disc-shaped corneal oedema.
- Neurotrophic keratopathy: reduced corneal sensation with persistent epithelial defects.
- Anterior uveitis with elevated IOP in keratouveitis.
- Reduced corneal sensation (hypoaesthesia) — common in HZO.
What OptoGuide™ covers for herpes zoster keratitis
- Pattern reasoning: what this combination of findings points to, and its differentiators
- Don't-miss risks and escalation triggers
- Management tiers with linked Australian therapeutics
- Referral urgency, specialty, and letter drafting
Sources
- Varicella Zoster Virus Stromal Keratitis and Endotheliitis — EyeWiki
- Herpes zoster ophthalmicus (HZO) — College of Optometrists CMG
- Anterior Eye Disease and Therapeutics A-Z (Bruce & Loughnan) — standard reference text
- Herpes Simplex Virus, Varicella-Zoster Virus and Cytomegalovirus Keratitis: Facts for the Clinician. Labetoulle M, Boutolleau D, Burrel S, Haigh O, Rousseau A. The Ocular Surface. 2023;28:336-350.
- Uveitis in Adults: A Review. Maghsoudlou P, Epps SJ, Guly CM, Dick AD. JAMA. 2025;334(5):419-434.
- Case 21-2009. Neilson EG, Farris AB. The New England Journal of Medicine. 2009;361(2):179-87.
Standard texts: Kanski's Clinical Ophthalmology: A Systematic Approach, The Wills Eye Manual, Oxford Handbook of Ophthalmology, Oxford American Handbook of Ophthalmology, Signs in Ophthalmology: Causes & Differential Diagnosis.