Eyeworld

85 EW CORNEA March 2017 10 years after they have had the zoster episode if their corneas were involved at all (not just the eyelids). "That is because their CMI from the zoster episode will protect them from getting zoster again," Dr. Tuli said. "However, the boost in their CMI and antigens from the vaccine may reactivate the inflammation that attacked their cornea previously and cause worsening of the ocular problems." Antivirals Dr. Tuli noted that there is no role for an oral antiviral or topical an- tiviral prophylactically prior to the vaccine in patients with a history of ocular involving disease. "Giving antivirals with the vaccination would make the vaccine ineffective since it is a live attenuat- ed vaccine," Dr. Tuli said. "We think the recurrence is due to the patient's immune system attacking the resid- ual viral antigen in the eye (from the previous episode of zoster). Antivi- rals would not help prevent that be- cause it is not live virus that attacks the cornea with vaccination." U.S. patients may soon have another vaccine option, which is undergoing drug trials. That vac- cine from GlaxoSmithKline is not an attenuated virus and in trials has shown 97% efficacy at blocking shingles, compared to about a 50% efficacy with the current vaccine, Dr. Margolis said. Importantly, patients vaccinated with the previously ap- proved option will be able to receive the coming vaccine if they are at high risk for shingles. EW References 1. Hwang CW, et al. Reactivation of herpes zoster keratitis in an adult after varicella zos- ter vaccination. Cornea. 2013;32:508–509. 2. Oxman MN, et al. A vaccine to prevent her- pes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352:2271–84. Editors' note: The physicians have no financial interests related to their comments. Contact information Margolis: MargolisT@vision.wustl.edu Tuli: stuli@ufl.edu Control and Prevention for those 60 years and older. "I think everyone 50 years and older should be getting vaccinated— but that's my opinion," Dr. Margolis said. Contraindications include allergies to any ingredients of the vaccine and patients who are im- mune compromised to an unknown degree. "It is a live, attenuated virus so you don't give this to someone who is severely immune compromised. There are different recommenda- tions based on the degree to which someone's immune system is com- promised," Dr. Margolis said. The vaccine is recommended even for people who have previously had zoster, Dr. Tuli said. There is no official recommendation as to how long after having zoster they should wait before they get the vaccine. Approaches vary Dr. Tuli tells patients with a history of non-ocular involving herpes zos- ter that they don't need it because their immune system and cell-me- diated immunity for zoster has been boosted for about 10 years "but that there is no harm in getting it." The Shingles Prevention Study (SPS) showed that the CMI that occurs due to an episode of shingles is equal to the CMI that develops as a result of vaccination. 2 "Therefore, getting shingles is like giving yourself a shingles vacci- nation," Dr. Tuli said. Dr. Margolis agreed that the chance of such patients developing another true episode within 5 years is low so there is no rush to get the vaccine. "Patients should get it but the question is when; there's no real data for that," Dr. Margolis said. However, in cases of active iritis or keratitis, Dr. Margolis tells patient not to get the vaccine. "I warn them that getting it has a small but real risk of causing their iritis or keratitis to recur or get worse because of the immune response to antigens in the eye," said Dr. Mar- golis, who has published reports on such iritis and keratitis cases. Similarly, Dr. Tuli recommends against the vaccination for at least

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