Ocular herpes is a condition often mistaken for regular pink eye. If you have long-lasting or especially severe keratitis (inflammation of the cornea), it could be a sign your condition is more serious than it first appeared. (Learn More)

Ocular herpes is first contracted through either the herpes simplex virus or herpes zoster, commonly called shingles.

Usually a person is first infected with the virus HSV-1 in their youth, and the virus can end up infecting the eye. This initial infection can go unnoticed, showing few symptoms (if any) or symptoms that are similar to pink eye.

Even if it seems to go away, it may lay dormant in the eye, causing future problems.(Learn More) This can alternatively happen with shingles, through a similar process, but generally later in life.

When the latent herpes reactivates, either randomly or through triggers that are difficult to determine, it can cause serious eye problems, including epithelial keratitis, stromal disease, and endotheliitis. (Learn More) While some of these diseases are more serious than others, all can cause blindness and other vision problems if left untreated.

Even if ocular herpes itself has no cure, it can be treated with medications, as can the diseases it causes. This is usually done with some mix of antivirals and steroids, depending on what your doctor deems appropriate.(Learn More)

There is not always an easy lab test to confirm ocular herpes, and it can be mistaken for a few conditions.(Learn more) If your doctor has been unable to diagnose your condition, or diagnosed you and your prescribed treatment is not working as it should, consider seeing a specialist to check if you were misdiagnosed or if there are other treatments available.

Ocular Herpes, HSV, and Shingles

Ocular herpes is sometimes difficult to diagnose. The condition is incurable, although is treatable. Once a person is infected, the virus will periodically reactivate, either randomly or through triggers.

When active, the virus can cause complications in the eye. Talk to a doctor as soon as possible if you have herpes simplex virus (HSV) or herpes zoster (shingles) and notice any eye-related issues. Speedy treatment can help to prevent serious damage and mitigate future risks.

One potential sign of ocular herpes is keratitis, an inflammation of the cornea. Herpes is not the only thing that can cause keratitis, but you should still see a doctor to determine how serious your condition is because of how serious any eye complication can be.

keratitis

What Causes HSV/Shingles?

HSV-1 is transmitted via oral fluids, while HSV-2 is transmitted via the genitals. It is HSV-1 that is commonly associated with ocular herpes.

While some associate herpes specifically with sexual contact, this is not necessarily how one gets the infection. HSV-1 can infect the genitals through oral sex, however.

Both conditions are chronic, although they can be managed with treatment.

Many people with HSV may be asymptomatic or mildly asymptomatic to the point that they do not notice their condition, spreading it accidentally. An estimated 67 percent of the world’s population has some form of HSV. It should be noted that this does not mean 67 percent of the world’s population has ocular herpes, which is much rarer.

HSV is usually first caught in youth, where symptoms may be mild or go unrecognized.

In the case of ocular HSV, this primary infection enters the eye and eventually reaches the trigeminal ganglion, going latent. It will remain there for life, occasionally traveling back to the cornea, which in turn causes chronic problems with eye disease through recurrent infections.

Shingles gets into the eye more rarely but with a similar effect. It is a serious condition in its own right, characterized by painful rashes caused by the same virus that causes chickenpox. If you have ever had chickenpox, you might develop shingles, although not everyone does. Additionally, even fewer people will have herpes zoster/shingles infect their eye.

Exactly what causes the recurrent infections that characterize ocular herpes is not entirely clear. Some proven triggers include the following:

  • UV light
  • Fever
  • Refractive surgery
  • Cold
  • Periods
  • Illness or high fever
  • Otherwise weakened immune system

Some people seem to be triggered randomly, and other patients anecdotally report a wide variety of triggers beyond the above list.

Stress is one commonly reported trigger, but the Herpetic Eye Disease Study (HEDS) group says it does not actually seem to be a trigger of HSV recurrent infections. They do additionally admit that stress is a difficult trigger to totally disprove, as it has such a wide variety of meanings from patient to patient.

man covering eye in pain

Common Confusions

There is no definitive test for the conditions sometimes caused by ocular herpes, with the exception of HSV epithelial disease (discussed later). Some conditions ocular herpes might be misdiagnosed as include:

  • Acanthamoeba infection.
  • Topical medication toxicity.
  • Healing abrasions.

According to Dr. James Chodosh, a doctor diagnosing diseases caused by ocular herpes might also find some difficulties over the lack of a simplified, widely accepted set of terminology. This can lead some doctors to improperly classify a given patient’s condition.

Epithelial Keratitis, Stromal Disease, and Endotheliitis

While ocular herpes can cause a variety of eye complications, the most serious is keratitis. There are essentially two types of keratitis: epithelial disease and stromal disease

Epithelial keratitis can cause redness, photophobia, tearing, blurred vision, and more in an infected eye. It is one of the most common manifestations of HSV keratitis and can cause serious vision problems and even blindness if left untreated.

Stromal keratitis (stromal disease) is very serious and can cause permanent blindness due to corneal scarring and astigmatism. There is also endotheliitis, a rare complication of ocular herpes, caused by endothelial problems in the eye. Like all of these complications, it can cause permanent damage left untreated. It is characterized by corneal edema, deposits on the corneal endothelium, mild eye pain, blurred vision, sensitivity to light, a small pupil, and redness.

Treatment

man using eyedrop

Epithelial keratitis is treated with antivirals. Meanwhile, stromal disease is treated with steroids and specifically oral antivirals. Endotheliitis is treated in a similar fashion to stromal disease, using steroids and then oral antivirals.

The specifics and risks of each disease related to ocular herpes vary. For example, doctors must be careful with steroids as they can actually make things worse if the diagnosis is incorrect.

Antivirals are meant to fight live virus replication. It is sometimes important to be on these for a while before being given steroids, as steroids can increase virus replication. Other times, a doctor may prescribe both antivirals and steroids at the same time.

When needed, antivirals that are applied to the eye are generally taken for seven to ten days to get control over a condition before they serve a new role as a prophylactic. A prophylactic is a treatment meant to prevent a disease from happening or, in this case, from recurring.

Antivirals come in oral (taken by mouth) and topical (applied directly to the eye) forms. Topical antivirals make poor prophylactics, as they can be toxic if taken for a long time.

Meanwhile, the goal of prescribing steroids is to keep the eye “quiet,” or in a stable state. In some cases, a patient may never be able to come off steroids once they are on them. Diseases caused by ocular herpes can be chronic, especially with stromal disease. That said, generally with endotheliitis, a patient will eventually be able to come off steroids.

A doctor will help you find the minimum dose of steroids you need by slowly tapering your dose. The idea is to find the precise dose needed since steroids come with their own set of negative side effects.

References

Demystifying the Ocular Herpes Simplex Virus. (January 2013). American Academy of Ophthalmology.

Herpes Simplex Eye Infections. (October 13, 2016). UK NHS.

Herpes Simplex Virus. (January 31, 2017). World Health Organization.

Keratitis. (November 8, 2018). Mayo Foundation for Medical Education and Research (MFMER).

Shingles. (May 16, 2018). Mayo Foundation for Medical Education and Research (MFMER).

The Three Faces of Herpes Simplex Epithelial Keratitis: A Steroid-Induced Situation. (April 2, 2015). BMJ Case Reports.

Herpes Simplex Virus Keratitis: A Treatment Guideline - 2014 (July 2014). American Academy of Ophthalmology.

Herpetic Epithelial Keratitis. (December 18, 2014). QJM: An International Journal of Medicine.

Treatment and Management of Presumed Herpes Simplex Keratouveitis With Endotheliitis. (2017). American Academy of Optometry.

Keratic Precipitates. Columbia University Department of Ophthalmology.