Eyeworld

92 | EYEWORLD | MARCH 2021 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians Elisabeth Cohen, MD Professor, Department of Ophthalmology NYU Grossman School of Medicine NYU Langone Health New York, New York Vincent de Luise, MD Assistant Clinical Professor of Ophthalmology Yale University School of Medicine New Haven, Connecticut W ith more than 1 million new cas- es each year, herpes zoster is in- creasing in frequency, according to Vincent de Luise, MD. As the population ages, the incidence increases, with an incidence of 1 in 3 overall and 1 in 2 in those over age 85. Dr. de Luise stressed that prompt diagnosis is essential, and systemic antivirals are required to reduce the viral load and reduce the incidence of post-her- petic neuralgia. Dr. de Luise and Elisabeth Cohen, MD, spoke to EyeWorld about the vaccine for herpes zoster that is now available, how to manage various complications associated with herpes zoster, and treatment options. Status of vaccines Shingrix (GlaxoSmithKline) is widely available now, Dr. Cohen said, adding that it may be more available at chain pharmacies than in doctors' offices. "The new one is much more effective and safer because it doesn't contain a live attenuated virus," she said. "In the U.S., there are not peo- ple who would be better off with the original vaccine, which is less effective and does have the risk of attenuated virus, which is a real risk in people who are immunocompromised." The Shingrix vaccine is FDA approved and is indicated for those 50 and older. Immuno- compromised patients were not included in the landmark studies, Dr. Cohen said, but there have been a number of papers since then show- ing that the vaccine is safe and effective in a va- riety of immunocompromised populations. "You don't have to worry about safety with regard to infection; there may be potential safety issues with regard to stimulating the immune system in people who have had transplants, but this has not been reported to date," she said. According to GlaxoSmithKline, there had been regional shortages in the last few years, but at this time, there are sufficient quantities, Dr. de Luise said. "The Shingrix vaccine is covered in some insurance plans as a preventative healthcare benefit," he said. "Study data has demonstrated that the Shingrix vaccine stimulates production of specific immune memory cells (CD4 T cells), generating strong and sustained protection against the virus, with a 24-fold increase in CD4 T cell response, significantly more than the older Zostavax [Merck] vaccine. The Shingrix vaccine efficacy lasts at least 4 years and likely longer." Dr. de Luise noted that as of July 1, 2020, Merck stated that it will no longer produce the Zostavax vaccine. Doses of Zostavax at phar- macies and clinics could have been used up until Nov. 18, 2020, so Shingrix is now the only vaccine for herpes zoster. Dr. de Luise said the Shingrix vaccine, given in two doses, is more than 90% protective effect against VZV, whereas Zostavax was only 51% effective in preventing disease. This also translates to a much higher rate of prevention against post-herpetic neuralgia for Shingrix than Zostavax, he said. Protection stays above 85% for at least the first 4 years. The two Shingrix injections are spaced 2–6 months apart. Side effects include pain and malaise for several days, especially in persons less than age 70. Should patients who have had herpes zoster receive Shingrix? According to Dr. de Luise, patients can receive Shingrix even if they've had a prior episode of herpes zoster. "Having had herpes zoster means that one has been exposed to wild-type virus," he said. "That produces a natural immune response." This natural immune response, largely a T cell response, usually lasts for several years and eventually decays. "If one wishes to receive the Shingrix vaccine, even if one has had a case of herpes zoster, the recommendation is to wait at least 3 months after an active herpes zoster in- fection to receive the vaccine," Dr. de Luise said. Dr. Cohen encouraged those who have had a herpes zoster episode to get the Shingrix vaccine. The purpose of the vaccine would be to prevent another episode in a different location, she said. "There isn't as much immunity after an episode of herpes zoster as we thought in the past," she said. "We used to think you could wait 1–3 years after an episode before getting vaccinated." Herpes zoster update

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