Herpes zoster ophthalmicus in the V2 dermatome post Shingrix vaccination

Herpes zoster ophthalmicus (HZO), a reactivation of latent varicella-zoster virus within the trigeminal nerve, most often involves the V1 (ophthalmic) division. However, reactivation in the V2 (maxillary) dermatome is less commonly discussed, yet it may still pose a significant risk to ocular structures.¹

As an optometric physician, I have treated many cases of HZO, chiefly before the older or newer Shingrix vaccine or in patients who were unvaccinated with either one. I had the unexpected opportunity to personally experience and manage a case of V2 zoster complicated by anterior uveitis and elevated IOP.

For this case study, I was the patient. This report documents my clinical course, diagnostic process, and treatment—both systemic and ocular. I received the Shingrix vaccinations 6 years ago. As a starting point, I initially did not recognize HZO until it evolved, albeit without the classic presentation. Often, we as professionals can diagnose herpes simplex virus (HSV) from across the room. This presentation certainly was not the case.

As a brief review, Shingrix is a nonlive recombinant vaccine designed to prevent herpes zoster (shingles), which is caused by varicella-zoster virus (VZV)—a herpesvirus cousin of HSV-1 and HSV-2. It contains glycoprotein E (gE) from VZV and the AS01B adjuvant, which supercharges the immune response. Reactivation of herpes zoster (VZV) after Shingrix is also reported occasionally, despite the vaccine's goal—possibly due to preexisting subclinical reactivations being unmasked. The very fact that the vaccine offers protection makes the eye care professional's diagnosis somewhat challenging.

Shingrix prevents shingles in over 90% of individuals and significantly reduces the risk of long-term nerve pain. It’s the Beyoncé of adult vaccines: strong, long-lasting, and fiercely protective.

HSV reactivation after Shingrix: What percentage are we talking about?

Here are what the (sparse but growing) data show: Based on case reports, the Vaccine Adverse Event Reporting System, and observational studies, the estimated rate of mild HSV reactivation after Shingrix vaccination ranges from around 0.05% to 0.1%. That is approximately 1 in 1000 to 1 in 2000 vaccine recipients.^2,3

Typically, reactivation is associated with mild cold sores, genital lesions, or ocular HSV flares. Importantly, events of HSV reactivation after Shingrix are rare, usually self-limited, and not clinically serious. In most cases, they respond quickly to antivirals (valacyclovir, acyclovir).^4,5 Now for my clinical course.

My clinical presentation

Day 1: Cutaneous onset

Mild erythema and a faint plaque just inferior to the right orbit were recorded. Additionally, small clustered vesicular lesions in the V2 distribution, lateral to the nasal bridge and beneath the infraorbital rim, were found. These lesions were subtle and could easily be mistaken for dermatitis or a nonspecific rash. There was no involvement of the nasal tip (Hutchinson sign negative) and no systemic symptoms or areas of inflammation. If I hadn’t had years of pattern recognition drilled into me, I might have missed the early signs entirely (Figure 1).

Day 2-3: Ocular involvement emerges

Onset of right eye redness, mild photophobia, and aching discomfort were recorded. Additionally, the slit lamp examination revealed 3-plus anterior chamber cells with significant flare, with visual acuity reduced to 20/40; no keratic precipitates or hypopyon; IOP of 30 mm Hg (normally I run 10-12 mm Hg), likely due to trabeculitis and a mild steroid response; and a clear posterior segment. The diagnosis was “zoster-associated anterior uveitis with ocular hypertension” (Figure 2).

Over the next 2 weeks, the lesions resolved completely, with IOP returning to baseline 11 mm Hg. VA returned to 20/20 corrected, and there was no pain or postherpetic neuralgia. The anterior chamber was completely clear of cells or flare (Figure 3).

Discussion and clinical pearls

Ultimately, zoster in the V2 dermatome may present subtly and be underrecognized. Ocular inflammation can occur even in the absence of V1 (forehead/eyelid) involvement. Keep in mind that an elevated IOP is not uncommon due to trabeculitis and steroid response: IOP must be closely monitored and controlled.

Additionally, initiating antiviral therapy within 72 hours is critical for minimizing complications. Topical corticosteroids and cycloplegics remain essential in managing anterior uveitis. In addition to treatment, patient education about recurrence, neuralgia, and Shingrix vaccination is vital for long-term care.

ICD-10 and CPT coding

• International Classification of Diseases, Tenth Revision (ICD-10) code for herpes zoster involving eye: B02.39 – Other herpes zoster eye disease
• ICD-10 for zoster with anterior uveitis: B02.32
• Current Procedural Terminology (CPT) code: 92004 or 92014 – Comprehensive eye exam
• CPT code: 92285 – External ocular photography (if documented)

Conclusion

My experience with V2-related HZO—and its ocular complications—underscores the importance of early recognition, aggressive therapy, and detailed follow-up. As both a provider and a patient, this case reinforced how deceptively mild zoster can appear, especially in breakthrough cases post vaccination in nonimmunocompromised patients, and how quickly it can involve the eye.

Something I have said previously that I stand by in my case is that: “Herpes zoster may show up quietly—but it doesn't stay that way. Catch it early. Treat it thoroughly.” I did have a local ophthalmologist help me manage the uveitis and IOP, and a local dermatologist consult and confirm the HSV. The dermatologist was quite impressed when I explained what I thought I had and agreed with the diagnosis, prescribing valacyclovir hydrochloride (Valtrex) and a topical agent.

My thanks to Jonathan M. Lam, MD, MBA, (ophthalmologist), and Jordan B. Schwartzberg, MD, (dermatologist). I did follow the rule that a lawyer who defends himself has a fool as a client.

Steve Silberberg, OD 

is the founder of a group practice, An Eye to the Future in Matawan, NJ, and is presently the program coordinator of CEwire.

Dr Silberberg is a frequently published author and consultant for the industry. He has served as VP of the Monmouth-Ocean Counties Society of Optometric Physicians, as a member-director for IDOC alliance, and was one of the original trustees of the American Association of Doctors of Optometry (AADO). He has served as one of the initial test writers for the ABO. He currently has several certifications in AI and is a frequent lecturer on AI and its ramifications in the optometric Field. His latest lecture on oculomics outlines the future of optometry in the diagnosis of systemic disease using AI.

Dr Silberberg graduated as departmental valedictorian from SUNY at Stony Brook before attending MIT on a full scholarship in planetary astrophysics. He then attended SUNY College of Optometry, graduating as class valedictorian along with winning the Beta Sigma Kappa award for vision science, the Fredrick Brock Award for Wxcellence in Vision Therapy, and the Ester Werner Award for Academic Excellence.

E: spacedoc@alum.mit.edu

References

1. Gagliardi AMZ, Andriolo BNG, Torloni MR, Soares BGO. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev. 2019;3(3):CD008858. doi:10.1002/14651858.CD008858.pub3

2. Willis ED, Woodward M, Brown E, et al. Herpes zoster vaccine live: a 10 year review of post-marketing safety experience. Vaccine. 2017;35(52):7231-7239. doi:10.1016/j.vaccine.2017.11.013

3. Dagnew AF, Ilhan MN, Lee WS, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine (Shingrix) in adults previously vaccinated with zoster vaccine live. J Infect Dis. 2021;224(9):1561-5.

4. Tseng HF, Harpaz R, Luo Y, et al. Declining effectiveness of herpes zoster vaccine in adults aged ≥ 60 years. J Infect Dis. 2016;213(12):1872-1875. doi:10.1093/infdis/jiw047

5. Harpaz R, Leung JW. The epidemiology of herpes zoster in the United States during the era of varicella and herpes zoster vaccines: changing patterns among older adults. Clin Infect Dis. 2019;69(2),341-344. doi:10.1093/cid/ciy143