MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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50 May 2013 EW CORNEA Cornea editor's corner of the world HZO vaccine-recurrence link? by Rich Daly EyeWorld Contributing Writer R ecurrence of varicella zoster virus (VZV) is a painful condition that can have long-term sequelae especially in the elderly. Post-herpetic neuralgia is a very painful complication and one that can have a serious effect on the quality of life of many individuals. The herpes zoster vaccine has been recommended for adults 60 years and older, and in some cases 50 years and older, whether or not the patient had a prior episode of VZV. Contraindications include history of anaphylactic/anaphylactoid reaction to any component of the vaccine or a history of primary or acquired immunodeficiency state or pregnancy. However, cornea specialists may be adding another relative contraindication: those patients with a history of prior herpes zoster ophthalmicus (HZO). There have been several reports of recurrence of HZO after patients received the herpes zoster vaccine. This month's "Cornea corner of the world" has Clara Chan, MD, Jay Pepose, MD, and Thomas Liesegang, MD, debating the pros and cons of the herpes zoster vaccine. Edward J. Holland, MD, cornea editor A growing number of case reports have identified reactivation of ocular inflammation from prior herpes zoster ophthalmicus following vaccination. Those reports have raised caution flags among some ophthalmologists. In one of the most recent cases, Charles W. Hwang Jr. and colleagues reported in the April issue of Cornea a patient's reactivation of herpes zoster keratitis and worsening of neurotrophic keratopathy, keratouveitis, and keratoconjunctivitis sicca after vaccination with live attenuated herpes zoster vaccine (Zostavax, Merck, Whitehouse Station, N.J.).1 The 63-year-old male patient's herpes zoster keratouveitis and neurotrophic keratopathy was quiescent for three and a half years without medication. But two weeks after administration of Zostavax he presented with keratouveitis, the authors reported. A possible cause of the recurrence was the vaccine-induced increase in cell-mediated immunity in a patient with persistent viral antigens in his cornea, they wrote. "Vaccination should be undertaken with caution in patients with a history of HZ ophthalmicus," Hwang and colleagues concluded. That precaution was echoed by Clara Chan, MD, clinical lecturer, Department of Ophthalmology, University of Toronto, after she saw mild recurrences of iritis after vaccination in some patients with a history of herpes zoster ophthalmicus. They required treatment with topical steroids. Even more concerning was the case of a colleague's patient with a history of treatable recurrent bouts over many years of mild HZV-related EyeWorld @EWNews Follow EyeWorld on Twitter at twitter.com/EWNews Find us on social media Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine HZO neurotrophic keratopathy keratitis and hypertensive iritis. Several weeks after she received a Zostavax vaccine, the patient developed a corneal stromal immune keratitis, followed within a few months by a rapidly progressing corneal melt, perforation and emergent therapeutic keratoplasty. It remains unclear whether the patient's deterioration was due to the enhanced immune response elicited by the vaccine or other factors. "The timing however, was quite suspicious, given the years of relatively innocuous herpetic zoster activity, followed by this angry, aggressive reaction shortly after vaccination," Dr. Chan said. As a result, she recommends against the zoster vaccination in patients with a history of HZO, thoracic zoster, and those who are immunocompromised. At least two other cases of reactivation of ocular inflammation in patients with HZO following the zoster vaccine have been published.2,3 Other reports have linked the zoster vaccine with post-vaccination ocular complications.4,5 The possible link between vaccination and recurrence of herpes zoster ophthalmicus has taken on greater importance in recent years as primary care physicians have increasingly urged administration of such vaccines, said Edward J. Holland, MD, professor of ophthalmology, University of Cincinnati, and director, cornea service, Cincinnati Eye Institute. "I recommend it for all my patients when they ask me if they should have it except for one group: patients with a history of herpes zoster ophthalmicus," Dr. Holland said. "I tell them not to get the vaccination until we get more data on who is at risk because we have an increasing number of case reports of reactivation of herpes zoster ophthalmicus after vaccination." However, no formal contraindication exists against the use of this vaccine in patients with a history of VZV-related infections, and one study actually argues for its safety.6 Thomas J. Liesegang, MD, professor of ophthalmology, Mayo Clinic, Jacksonville, Fla., has examined the possible connection between the zoster vaccine and recurrence after reports of a link. "Theoretically, there are reasons to think it might exacerbate previous ocular inflammation related to HZO, but this must be rare since we are not seeing it clinically very often," Dr. Liesegang said. Ocular inflammation from herpes zoster ophthalmicus can recur or recrudesce on its own even in the absence of the vaccine, he said. As a consequence, any link is difficult to establish with certainty. The lack of a clear connection has led Dr. Liesegang to continue to recommend the zoster vaccine for all patients over age 50 except for those who are immunocompromised or on steroids.

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