Eyeworld

EW CORNEA 84 March 2017 by Rich Daly EyeWorld Contributing Writer gy, University of Florida, Gainesville, Florida, co-authored a case report on a 63-year-old man with a history of HZ keratouveitis and neurotrophic keratopathy, who was quiescent for 3.5 years off medication but present- ed with keratouveitis 2 weeks after Zostavax administration. 1 That case report was published in 2013 and Dr. Tuli said he has had two additional such cases since then. "All were stable before the vaccination and had recurrence of their ocular inflammation about 2 to 3 weeks after getting the shingles vaccine," Dr. Tuli said. Todd Margolis, MD, PhD, Alan A. and Edith L. Wolff Distinguished Professor and chairman, Department of Ophthalmology, Washington Uni- versity School of Medicine, St. Louis, has similarly cared for patients with recurrent keratitis and iritis soon after vaccination with Zostavax. "It appears to be a reactivation of the disease," Dr. Margolis said. "I don't think it is a reactivation of the virus. You just boosted the immune response with the vaccination and these patients have immunological driven disease in the eye." The findings have led some oph- thalmologists to urge caution before providing the vaccine to patients with a history of HZ ophthalmicus. Recommendations The vaccine is approved for individ- uals 50 years and older and recom- mended by the Centers for Disease New Jersey) was first approved in 2006 by the U.S. Food and Drug Administration. That approval has been expanded to include individu- als age 50 years and older. However, the safety of the vaccine in patients with a history of zoster has not been comprehensively studied. Individual cases continue to emerge in which patients with a history of HZ keratitis with per- sistent viral antigens in their corneas develop recurrence of keratouveitis because of the vaccine-induced increase in CMI. Sonal Tuli, MD, professor and chair, Department of Ophthalmolo- When to avoid the herpes zoster vaccine Nummular keratitis (coin-shaped lesions) that appeared after zoster. Source: Sonal Tuli, MD S hingles or the recurrence of varicella zoster virus (VZV) can be a very pain- ful experience for a patient. Particu- larly in the elderly population, there may be long term sequelae, including post-herpetic neuralgia, which can significantly decrease the quality of life for the patient. The herpes zoster vaccine is recom- mended for those 50 years of age or older regardless of whether or not the patient had a prior episode of VZV. Patients who are immunosuppressed, pregnant, or have a history of allergy to any component of the vaccine should avoid the vaccine. Ophthalmologists certainly see patients with acute herpes zoster ophthal- micus (HZO) ora related chronic sequelae, as well as those with a history of prior HZO. There have been several reports of HZO recurrence after patients receive the vaccine, thus some cornea specialists argue that recent prior HZO may be considered a relative contraindication. In this month's "Cornea editor's corner of the world," Sonal Tuli, MD, and Todd Margolis, MD, PhD, discuss their clinical experience and recommendations about which ophthalmic patients may or may not benefit from the herpes zoster vaccine. Clara C. Chan, MD, FRCSC, FACS, Cornea editor Evidence continues to build that some patients may want to avoid the vaccine E vidence continues to emerge that patients vacci- nated for herpes zoster (HZ) can develop a recurrence of keratouveitis because of the vaccine-induced increase in cell-me- diated immunity (CMI). Avoiding vaccination in some individuals with previous zoster infections may be prudent. A shingles, or HZ, vaccine (Zos- tavax, Merck, Whitehouse Station, for the addressing of most ocular surface issues. However, 5% of his patients need more treatment and thus require a delay in surgery. This conversation usually goes well, he said. "Individualizing their care often makes the patients understand our commitment to a great outcome," he added. When it comes to candidacy for multifocal or extended depth of focus IOLs, Dr. Zavodni said he'll tell mild dry eye patients his recommen- dation will depend on their response to treatment. For those with mod- erate to severe dry eye, however, Dr. Zavodni said he'll usually recom- mend against these advanced optics because they are more likely to be frustrated by the quality of their post-operative vision. "Obviously, I may tailor my dis- cussion based upon the response to dry eye therapy seen at subsequent visits," he added. In patients who are receiving advanced IOLs after responding well to dry eye treatment, Dr. Yeu makes sure to tell them they might need to maintain some sort of dry eye regimen—drops or a longer-term office-based thermal procedure—to ensure their vision continues to perform at the highest level. Dr. Zavodni said he will tell his dry eye patients that they might have more postoperative irritation in the weeks following surgery and it also might take them longer than average to reach their best visual acuity. EW Editors' note: Dr. Yeu has financial in- terests with TearLab (San Diego), Rapid Pathogen Screening (Sarasota, Florida), TearScience, Bio-Tissue, Shire (Lex- ington, Massachusetts), and Allergan (Dublin). Dr. Kieval has financial inter- ests with Abbott Medical Optics (Abbott Park, Illinois), Allergan, Shire, and Sun Pharmaceutical (Mumbai, India). Dr. Zavodni does not have any financial interests related to his comments. Reference 1. Epitropoulos A, et al. Effect of tear osmolar- ity on repeatability of keratometry for cataract surgery planning. J Cataract Refract Surg. 2015;41:1672–7. Contact information Kieval: jkieval@gmail.com Yeu: eyeulin@gmail.com Zavodni: zacharyzavodni@gmail.com Prepping continued from page 80 Cornea editor's corner of the world

• Blank Page
• Blank Page (1)