Persistent Eyelid Swelling After Herpes Zoster Ophthalmicus
You need an urgent ophthalmology evaluation within the next few days to assess for ongoing inflammatory complications such as uveitis, keratitis, or secondary glaucoma, which commonly develop weeks to months after the initial herpes zoster ophthalmicus infection and require specific treatment beyond the acute phase.
Why This Requires Ophthalmology Referral Now
Persistent eyelid edema one month post-infection is not part of the normal resolution timeline and signals potential ongoing ocular complications that threaten vision:
- Late inflammatory complications occur in 29-50% of herpes zoster ophthalmicus patients and typically manifest weeks after the initial rash resolves, including stromal keratitis, uveitis, secondary glaucoma, and chronic ocular inflammation 1, 2.
- Corneal complications develop in 38-61% of herpes zoster ophthalmicus cases and follow a specific temporal pattern: early lesions (punctate keratitis, pseudodendrites) occur acutely, while delayed complications (disciform keratitis, neurotrophic keratitis, exposure keratitis) emerge weeks to months later 3, 4.
- Conjunctival scarring from secondary bacterial infection can lead to cicatricial ectropion, which causes persistent lid malposition and chronic inflammation 5.
What the Ophthalmologist Will Assess
The specialist needs to perform slit-lamp biomicroscopy to identify specific complications that cannot be detected by external examination alone:
- Corneal involvement: Look for delayed mucous plaques (13% incidence), disciform keratitis (10%), neurotrophic keratitis (25%), or exposure keratitis (11%) 3.
- Anterior segment inflammation: Assess for kerato-uveitis/endotheliitis (34% incidence), which requires topical corticosteroids under close monitoring 3.
- Secondary glaucoma and iris damage: Check intraocular pressure and examine for sectoral iris atrophy, both of which occur as late sequelae 1, 4.
- Lid margin scarring: Evaluate for cicatricial changes causing mechanical irritation and chronic inflammation 5.
Treatment Will Depend on the Specific Finding
The ophthalmologist will tailor therapy based on what is causing the persistent swelling:
If Active Inflammation Without Epithelial Disease
- Topical corticosteroids (fluorometholone or loteprednol preferred for lower side-effect profile) can be initiated, but only after confirming no active epithelial viral infection, as steroids potentiate viral replication 1, 6.
- Requires regular intraocular pressure monitoring and pupillary dilation to screen for steroid-induced glaucoma and cataract 1.
If Neurotrophic or Exposure Keratitis
- Aggressive lubrication with preservative-free artificial tears and ointment at night 1.
- Possible punctal occlusion or tarsorrhaphy if severe 3.
If Secondary Bacterial Infection of Vesicular Lesions
- Topical antibiotics to prevent progression to severe conjunctival scarring 1.
If Cicatricial Lid Changes
- May require surgical correction if causing chronic mechanical irritation 5.
Critical Pitfalls to Avoid
- Never use topical corticosteroids without ophthalmology supervision in herpes zoster ophthalmicus, as they are absolutely contraindicated during active epithelial viral infection and can worsen disease 1, 6.
- Do not assume the infection has fully resolved just because the rash has healed—late ocular complications are common and can be sight-threatening 2, 7.
- Do not delay referral—permanent sequelae including chronic ocular inflammation, corneal scarring, and vision loss occur when complications are not promptly identified and treated 7.