On the first day of the 2026 Optometry’s Meeting in Phoenix, attendees learned all about herpetic eye disease from Joseph P. Shovlin, OD, FAAO. His presentation provided a comprehensive clinical review of ocular herpes simplex virus (HSV) and herpes zoster virus (VZV) that emphasized diagnosis, management, and emerging evidence related to chronic disease prevention. He highlighted that HSV-1 remains the most common ocular viral pathogen, while herpes zoster ophthalmicus (HZO) continues to increase in prevalence as the population ages. He noted that both viruses establish lifelong latency within sensory ganglia and may reactivate when cell-mediated immunity declines.
For clinicians, HSV should remain high on the differential when encountering unexplained unilateral conjunctivitis, keratitis, iritis, or elevated intraocular pressure. The 4 major corneal manifestations of HSV are epithelial keratitis, stromal keratitis, endotheliitis, and neurotrophic keratopathy. Dr. Shovlin emphasized the importance of distinguishing infectious epithelial disease from immune-mediated stromal disease because treatment strategies differ significantly. Topical and oral antivirals are effective for epithelial disease, while corticosteroids remain the cornerstone of stromal and endothelial inflammation management when combined with antiviral coverage.
Practitioners may also face diagnostic challenges. For example, dendriform lesions may mimic Acanthamoeba keratitis, healing abrasions, contact lens-related pseudodendrites, or herpes zoster keratopathy. Persistent epithelial defects and poor therapeutic response should prompt consideration of neurotrophic disease, medication toxicity, antiviral resistance, or systemic immunocompromise.
Dr. Shovlin also explained that HZO has devastating ocular and systemic complications. Without antiviral treatment, ocular involvement occurs in up to 70% of patients. Chronic keratitis, uveitis, glaucoma, neurotrophic keratopathy, and postherpetic neuralgia (PHN) remain significant sources of morbidity. Emerging evidence from the Zoster Eye Disease Study (ZEDS) suggests that 1 year of suppressive valacyclovir therapy can reduce recurrent inflammatory episodes and chronic pain burden in selected HZO patients, providing clinicians with a new evidence-based strategy for long-term management.
One of the most challenging sequelae of recurrent HSV and HZO is neurotrophic keratopathy. Modern treatment approaches include amniotic membrane therapy, cenegermin, autologous serum, scleral contact lenses, tarsorrhaphy, and corneal neurotization procedures. The overarching clinical message is clear: Early recognition, careful differentiation between infectious and inflammatory disease, appropriate antiviral use, and vigilant long-term monitoring are essential to preserving vision and reducing complications in patients who have ocular herpes disease.OM