Herpetic Glaucoma (Herpes Simplex Virus)
Herpes simplex virus can inflame the eye's drainage tissue, causing sudden, sometimes severe, spikes in eye pressure that require careful, coordinated treatment.
Overview
Herpetic glaucoma is a secondary glaucoma caused by herpes simplex virus (HSV) infection of the eye. HSV can inflame the iris (iritis/uveitis) or the inner lining of the cornea (endotheliitis), and that inflammation frequently involves the trabecular meshwork itself — a process called trabeculitis — which can cause sudden, sometimes very high, spikes in eye pressure.
Symptoms
- Red, painful eye, often recurrent
- Light sensitivity (photophobia)
- Blurred vision
- Episodes that recur in the same eye over months to years
How Common Is It?
Ocular herpes simplex is one of the leading infectious causes of corneal disease in the developed world, and a meaningful proportion of patients with HSV keratouveitis develop at least one episode of elevated eye pressure during an active flare.
Because episodes tend to recur in the same eye, herpetic glaucoma is usually unilateral (affects one eye), and the risk of elevated pressure tends to rise with each subsequent flare.
Genetics & Risk Factors
There isn't a well-established inherited genetic pattern for herpetic glaucoma the way there is for some other conditions on this page; risk is driven mainly by prior exposure to and reactivation of the virus rather than family history.
Reactivation is often triggered by stress, illness, sun exposure, immune suppression, or trauma to the eye, similar to how cold sores can reactivate on the skin.
Ocular Findings on Exam
A key corneal sign is the dendrite: a branching, tree-like ulcer on the surface of the cornea with characteristic swollen (terminal bulb) ends, best seen with fluorescein dye under blue light. A dendrite is a hallmark, near-diagnostic finding of active HSV epithelial keratitis.
Iris transillumination defects — patchy areas where light passes through the iris because of focal loss of its pigment layer — are a hallmark exam finding in HSV-related iridocyclitis. These defects should be considered whenever a patient presents with high eye pressure and only mild anterior uveitis, since that combination is a recognized pattern for herpetic disease. Herpetic transillumination defects are typically patchy and asymmetric, and the condition is usually unilateral, affecting one eye at a time.
During active flares, the eye typically shows only mild-to-moderate inflammation (a relatively quiet-looking eye) despite a disproportionately high pressure reading — a pattern that should raise suspicion for a herpetic or viral cause.
Testing & Diagnosis
- Slit-lamp exam with fluorescein staining to look for a corneal dendrite
- Careful iris exam (including retroillumination) to look for transillumination defects
- Intraocular pressure measurement during the flare, since it can spike quickly
- Blood test for elevated IgM HSV antibodies, which can support the diagnosis in less clear-cut cases
- PCR testing of ocular fluid in atypical, severe, or treatment-resistant presentations
- Gonioscopy and optic nerve imaging once the acute flare has settled, to assess for any lasting damage
Treatment Options
Antiviral Therapy
Oral antiviral medication (such as acyclovir or valacyclovir) to treat the underlying viral infection and reduce recurrence.
Careful Steroid Use
Topical steroids to control inflammation, tapered thoughtfully and monitored closely for pressure spikes.
Eye Pressure Control
IOP-lowering drops during active flares; prostaglandin-class drops are sometimes avoided during active inflammation since they may worsen it.
Surgery for Chronic Cases
Glaucoma surgery may be needed if recurrent inflammation leads to chronic, medication-resistant elevated pressure.
How This Differs From Other Glaucomas
Herpetic glaucoma is unusual in that the eye often looks only mildly inflamed while the pressure spikes dramatically — the opposite pattern from most other inflammatory (uveitic) glaucomas, where severe inflammation is obvious. Recognizing a corneal dendrite or iris transillumination defects in this setting is often what points to the correct diagnosis.
Treatment also requires a distinctive balancing act: the steroid drops needed to control the inflammation can themselves raise eye pressure further, so dosing and tapering are managed more cautiously than in non-infectious glaucomas, alongside antiviral therapy that most other glaucomas don't require at all.
Frequently Asked Questions
Can herpes simplex really affect the eye's pressure?
Yes. HSV can inflame the eye's drainage tissue directly (trabeculitis), and the steroid drops used to treat the inflammation can also raise pressure — both need careful monitoring.
Will herpetic glaucoma come back?
It can recur, especially with future herpes flares. Long-term antiviral therapy is sometimes used to reduce how often flares occur.
Is this the same as shingles-related glaucoma?
No. Herpetic glaucoma here refers to herpes simplex virus (HSV). Glaucoma from shingles (herpes zoster) is a related but distinct condition — see our page on Herpes Zoster Ophthalmicus (Shingles) Glaucoma.
How is HSV confirmed as the cause?
Diagnosis is usually clinical, based on the characteristic corneal dendrite and pattern of inflammation. In less clear-cut cases, a blood test for elevated IgM HSV antibodies can support the diagnosis, and PCR testing of eye fluid is sometimes used for atypical or severe presentations.
See a glaucoma specialist. Dr. Robert Gunzenhauser is Harvard-educated and UCLA fellowship-trained in glaucoma, providing expert diagnosis and treatment for Herpetic Glaucoma at Inland Glaucoma Center in Upland, CA.