Eye Herpes (Ocular Herpes): Symptoms and Treatment

Eye herpes, also called ocular herpes, is an infection of the eye with the herpes simplex virus (HSV), mainly HSV-1, the strain that causes cold sores on the mouth. It can cause sores on the eyelid or on the outer layer of the cornea, the clear front of the eye. Symptoms include eye pain, redness, blurred vision, sensitivity to light and a watery discharge. If you have any of them, take out your contact lenses if you wear them and call us right away at 310-828-2010 for a same-day exam, or go to an emergency room when we're closed. The infection usually heals without damaging the eye, though more severe infections can scar the cornea, and it can come back. Don't put steroid drops in the eye before an exam.

Key takeaways

The cold sore virus, herpes simplex type 1, can infect the eye, often as a flare-up of an earlier infection, most commonly one of the mouth.
Treatment is antiviral medicine as drops, gel or pills, and steroid drops can make herpes worse, so never use leftover steroid drops before an exam.
Eye pain, redness, blur, light sensitivity or watery discharge means taking out contacts and calling us right away, or an emergency room when we're closed.
Sudden loss of vision in one or both eyes, even if it comes back, means calling 911.

What is eye herpes?

It's an infection of the eye with a herpes virus, the type of virus that causes cold sores and genital herpes, and the National Eye Institute (NEI) calls it ocular herpes.

An infection of the cornea itself is called HSV keratitis, and HSV-1, the strain that causes cold sores on the mouth, is its primary cause. Keratitis means inflammation (redness and swelling) of the cornea.

The virus behind it is common: more than half of people in the U.S. have been infected with type 1 herpes virus by their 20s.

If ocular herpes spreads deeper into the cornea or the other layers of the eye, it can become a serious keratitis, which can scar the cornea and cause vision loss. The CDC calls HSV keratitis a major cause of blindness worldwide.

What are the symptoms of ocular herpes?

The CDC lists these symptoms of HSV keratitis:

Eye pain
Eye redness
Blurred vision
Sensitivity to light
Watery discharge

Sores can also form on the eyelid.

A red eye can have many causes, from mild irritation to serious infection or inflammation; our urgent eye care page lists the red eye causes we see the same day. HSV keratitis is usually diagnosed from your health history and an eye exam, and lab tests aren't usually necessary. Tell us if you've had cold sores or eye herpes before.

How do you get eye herpes?

HSV spreads through direct contact with someone who has the virus. Most HSV keratitis infections happen after the virus has already infected another part of the body, most commonly the mouth, and the eye infection is often a flare-up (reactivation) of that earlier infection.

Contact lens wearers can get HSV keratitis, and so can people who don't wear lenses.

To lower your risk, the CDC advises:

Washing your hands thoroughly before touching your eyes, especially when you have a cold sore or herpes blisters
Using only eye drops that an eye doctor or other health care provider has prescribed or recommended

When is eye herpes an emergency?

Any of these symptoms is urgent: eye pain, redness, blurred vision, light sensitivity or a watery discharge. Take out your contact lenses if you wear them, then call us right away for a same-day exam, or go to an emergency room when we're closed.

A shingles rash on your forehead, eyelids or nose, including the tip of the nose, needs care the same day: come in to us or see your doctor. When offices are closed, see your doctor or an urgent care clinic the same day. Shingles antivirals should start as soon as the rash appears, and the CDC says to contact your doctor as soon as possible if you think you have shingles. If the eye itself is red, painful or sensitive to light, or your vision blurs, call us right away for a same-day exam, or go to an emergency room when we're closed.

Call 911 for sudden loss of vision in one or both eyes, even if it comes back, or for any change in vision with face drooping, arm weakness or trouble speaking, which can be signs of a stroke.

During office hours (Monday 10am to 5pm, Tuesday to Friday 8am to 5pm), calling first gets you triaged fastest, and we work urgent cases into the same day; our page on same-day urgent eye care explains how it works.

How is eye herpes treated?

With antiviral medicine, which helps control the virus and prevent damage to the cornea. Treatment usually involves eye drops or antiviral pills taken by mouth. Prescription antiviral eye medicines include:

Trifluridine eye drops, approved for a first herpes simplex infection of the cornea and conjunctiva (primary keratoconjunctivitis; the conjunctiva is the thin covering of the white of the eye) and for repeat infections of the corneal surface (recurrent epithelial keratitis). The most frequent side effects on the label are mild, brief burning or stinging (4.6%) and eyelid swelling (2.8%).
Ganciclovir 0.15% gel (Zirgan), approved for acute herpes infection of the cornea with branching sores (dendritic ulcers). Its most common side effects are blurred vision (60%) and eye irritation (20%).

Use them exactly as prescribed. Some treatments can greatly lower the severity and recurrence of symptoms, though there is no cure for HSV.

Why steroid drops need an exam first

Steroid eye drops treat inflammation, but they can make a herpes infection worse. The label for Pred Forte (prednisolone acetate), a prescription steroid drop, says it must not be used in most viral diseases of the cornea and conjunctiva, including herpes simplex infection of the corneal surface (dendritic keratitis). It also warns that eye steroids may prolong and worsen many viral eye infections, herpes simplex among them.

For people with a history of herpes simplex, the same label calls for great caution and frequent slit lamp exams, a microscope check of the eye. So never put leftover steroid drops, or anyone else's, in a red eye before it has been examined. If your eye doctor prescribes a steroid drop after examining your eye, use it exactly as directed and keep every follow-up visit; the label says care should be taken not to stop treatment too early.

Can eye herpes come back?

Yes. People who have had HSV keratitis are at risk for recurrences of the same infection, so any of the same symptoms needs a same-day exam again: call us right away, or go to an emergency room when we're closed.

Tell any eye doctor or surgeon about past eye herpes. The FDA lists herpes simplex or shingles involving the eye area among the conditions to discuss with your doctor before LASIK.

How is eye herpes different from shingles in the eye?

Shingles comes from a different virus. It is caused by varicella-zoster virus, the same virus that causes chickenpox, which stays in the body after chickenpox and can reactivate later in life.

Shingles that affects the ophthalmic division of the trigeminal nerve, the nerve that serves the forehead and eye, is called herpes zoster ophthalmicus, and it can cause eye problems, including vision loss. NEI advises a comprehensive eye exam if you get shingles on your face or in your nose or eyes.

	Eye herpes	Shingles in the eye
Virus	Herpes simplex virus, mainly HSV-1 (the cold sore strain)	Varicella-zoster virus (the chickenpox virus)
How it starts	Direct contact, or a flare-up of an earlier infection, most commonly of the mouth	The chickenpox virus reactivating later in life
What you may notice	Eye pain, redness, blurred vision, light sensitivity and watery discharge; sometimes sores on the eyelid	A painful rash on one side of the face, which can affect the eye
Treatment	Antiviral eye drops, gel or pills	Antiviral medicine, started as soon as the rash appears

Shingles is a painful rash that develops on one side of the face or body, and on the face it can affect the eye and cause vision loss. Our shingles and the eye page covers what shingles can leave behind in the eye and how we follow it.

How we treat eye herpes at Cohenmehr Optometry

We see painful, red, light-sensitive eyes the same day during office hours (an emergency room when we're closed). The same-day urgent eye care visit includes a slit lamp exam (a microscope view of the front of the eye), eye pressure testing and an evaluation of the cornea.

Our optometrists in Los Angeles treat infectious keratitis urgently with targeted drops, sometimes pills too, and recheck until the cornea is quiet, because scarring near the center of your vision is what we work to prevent; see how we treat keratitis.

For shingles near the eye, we evaluate the same day during office hours and coordinate antiviral care with your physician; when we're closed, see your doctor or an urgent care clinic the same day, or go to an emergency room if the eye itself is red, painful or sensitive to light or your vision blurs. When a surgeon or retina specialist is needed, the referral and records move the same day.

Questions patients ask

Do antibiotic eye drops work for eye herpes?

No. Antibiotics only treat certain bacterial infections and don't work on viral infections. Eye herpes is caused by a virus, so it's treated with antiviral medicine that helps control the virus and protect the cornea. If you were given antibiotic drops and the eye is getting more painful, red or sensitive to light, call us right away for a same-day exam, or go to an emergency room when we're closed.

Can eye herpes cause corneal scarring?

Yes, when the infection is severe. It usually heals without damaging the eye, but more severe infections can scar the cornea or cause blindness; surgery is rarely necessary but may be considered when a scar causes vision problems. When a scar leaves the corneal surface irregular, a fluid-filled scleral lens for corneal scarring can give light a smooth new surface to enter through, and a diagnostic lens trial shows how much vision the eye can still reach.

Can you wear contacts with eye herpes?

Not while the eye has signs or symptoms of it, or while you're using the medicine. The label for ganciclovir gel (Zirgan) says patients shouldn't wear contact lenses if they have signs or symptoms of herpetic keratitis or during the course of therapy, and with keratitis we keep lenses out until the cornea is quiet. Later on, the CDC notes that people who have had HSV keratitis are at risk of it coming back, and that wearing contact lenses may further increase that risk.

How long does eye herpes take to heal?

With treatment, sores on the surface of the cornea healed in about 6 to 12 days on average in the studies on the trifluridine eye drop label. In its controlled trial, 92 of 97 patients healed within the 14-day treatment period, branching (dendritic) sores in an average of 6 days and larger, map-shaped (geographic) sores in 7. In patients whose infection hadn't responded to other antiviral eye medicines, or who couldn't tolerate them, map-shaped sores took 12 days on average. We recheck until the cornea is quiet.

Sources

Written by

Dr. Kevin Cohenmehr, OD

Medical eye care: glaucoma, diabetic eye exams, macular degeneration and eye infections, plus vision therapy for children. A graduate of UCLA and SUNY College of Optometry.

About Dr. Kevin →

Eye Herpes (Ocular Herpes): Symptoms, Causes and Treatment