The Considerable Toll of Herpes Zoster Ophthalmicus Is Also Avoidable

Christopher J. Rapuano, MD


June 17, 2020

Many clinicians acknowledge that herpes zoster (or shingles) is not something they would wish to have, but they also seem to believe it just comes and goes. This could explain the rather low rate of vaccination since the zoster vaccine live (Zostavax) was approved in 2006. The Centers for Disease Control and Prevention currently recommends the recombinant zoster vaccine (Shingrix), approved in 2017, for immunocompetent patients aged 50 years or older who are not allergic to the vaccine. This two-dose vaccine is given 2-6 months apart. Although there have been issues with availability of this vaccine, it is less of a problem now.

Perhaps the vaccination rate would increase if herpes zoster ophthalmicus (HZO), an ocular form of herpes zoster with potentially devastating consequences including vision loss, was more well known.

In a recently published retrospective study, investigators queried a large medical claims and electronic health record database, reporting that the overall incidence of HZO in the United States increased 3.6% per year from 1994 to 2018. They concluded that "greater efforts should be made to vaccinate eligible adults 50 years of age and older." This study is accompanied by an editorial on behalf of the American Academy of Ophthalmology's Public Health Committee and a commentary from Dr Elisabeth Cohen, which both stress the importance of vaccinations, especially for herpes zoster. The editorial's authors suggest that ophthalmologists and their staff be familiar with the up-to-date vaccination schedules and encourage their patients to follow them—advice I wholeheartedly support. Cohen further notes the importance of developing evidence-based treatment standards for those who have HZO, including the National Eye Institute–supported multicenter Zoster Eye Disease Study comparing oral valacyclovir against placebo for anterior segment complications of HZO.

Ocular Sequelae Are Often Severe

As a cornea specialist, I care for several patients with HZO. While it is true that the forehead and facial rashes do come and go, the postherpetic neuralgia can be incapacitating. Although neuropathic pain medications, such as gabapentin and pregabalin, have been successful at diminishing the painful symptoms, they have not eliminated them and, of course, have their own adverse effects.

The most frequent ocular sequelae in my patients with HZO involve the anterior segment, often in the form of keratitis, iritis, and glaucoma. Although these conditions usually respond to anti-inflammatory medications, such as topical or (rarely) systemic steroids, they can also have their own set of complications, including steroid-induced glaucoma and cataracts.

The main issue is that the inflammation often recurs. It is well known that the inflammation is more likely to recur as the steroid medications are being tapered, but can absolutely recur with no change in the steroid regimen, often years after the episode of shingles. The more frequent and severe the recurrences, the more harmful the damage to the eye, including permanent corneal scarring and neovascularization.

By helping all clinicians better understand the consequences of HZO, we may increase vaccination rates against herpes zoster. We may also see this debilitating eye disease less frequently in our ophthalmology clinics.

Christopher J. Rapuano, MD, is a nationally and internationally recognized expert in corneal diseases, chief of the Wills Eye Hospital Cornea Service, and professor of ophthalmology at Sidney Kimmel Medical College at Thomas Jefferson University.

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