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BLOG: What’s the role of the eye care provider in preventing shingles?
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I work in a veteran’s hospital, so I see a lot of older patients. Recently the emergency room called up to the eye clinic and asked us to see a 75-year-old patient with a new rash they diagnosed as shingles; specifically, they wanted to know if his herpes zoster ophthalmicus was affecting his globe.
When I saw the patient, I could see his rash wasn’t too bad, but he looked pretty uncomfortable.
The ER had started oral famciclovir, 500 mg three times daily for 7 days. The patient’s ipsilateral conjunctiva and cornea were clear, and there were no signs of uveal or retinal involvement. He did have herpes zoster ophthalmicus (HZO), because the rash was in the dermatome of the ophthalmic branch of the trigeminal nerve (V1), but he didn’t have globe involvement.
We sent the patient back to the ER, and, as luck would have it, my next patient had a history of shingles a year ago. This patient was also pretty uncomfortable, but in a different way – he was suffering from post-herpetic neuralgia (PHN). Last year he had the classic V1 distribution of the zoster rash but had waited to go to the doctor until the rash was quite severe and painful. He was put on oral antivirals back then and his vesicles dissipated, but the nerve pain was always there.
PHN can be a devastating consequence of the disease and occurs in 10% to 17% of HZV patients, with increased severity after age 60. And of course, HZO can affect the globe as well, causing anything from a mild conjunctivitis with punctate keratopathy to a severe disciform keratitis with uveitis.
As eye care providers, we are trained how to spot HZO and how to treat it, but this month I wanted to explore what’s being done to prevent it. There are two shingles vaccines on the market today, Shingrix (zoster vaccine recombinant, adjuvanted, GSK) and Zostavax (zoster vaccine live, Merck). If humans start getting vaccinated for shingles, then we will see a lot less HZO in our practices, and hopefully that will mean fewer patients suffering from PHN. So, what do we need to know about the vaccines?
These vaccines work by boosting the cell-mediated immune response to varicella zoster virus (VZV) – remember, HZV is just a reactivation of VZV, the chicken pox virus. With age (or immunocompromise) this immunity declines, and up to 40% of people over 55 who had VZV as a child no longer have any detectable VZV-specific T cell responses. Even if the vaccine doesn’t prevent a shingles attack, it will lessen the severity; a robust VZV cell-mediated immunity is correlated with reduced severity of the disease and less risk of PHN. Also, you don’t have to prove the patient was exposed to varicella zoster or herpes zoster prior to vaccination; more than 96% of people living in America for more than 30 years have serologic evidence of prior varicella zoster.
Of the two vaccines, Zostavax came out first in 2006. This is a live attenuated vaccine that just needs one dose and is recommended in people older than 60 years. Zostavax was used for the last 12 years and is still used now in some cases, but the CDC (and other boards) now recommend Shingrix, which came out in October 2017. Shingrix is a non-live recombinant vaccine that needs two doses (given intramuscularly), with the second dose given 2 to 6 months after the first. Shingrix is recommended for people older than 50 years, mainly because it has better efficacy and the resultant immunity lasts longer.
In one trial, 15,411 people older than 50 years were given Shingrix, and after 3 years it prevented HZV in 90% compared to placebo. Also, the vaccine was 89% effective against PHN compared to placebo. As far as duration of immunity benefits, Zostavax showed less than 50% efficacy after 5 years and no efficacy after 8 years. Although there are no long-term data, the evidence shows less concern for waning immunity with Shingrix; given after 4 years of study there is still good protection. This waning immunity with Zostavax is the main reason why it’s only recommended for people older than 60, whereas Shingrix is recommended for anyone older than 50.
It’s exciting times for zoster prevention, and while herpes zoster isn’t on the minds of many of our patients, maybe it should be. The pain of PHN can be intense, severely affecting quality of life and lacking good treatment options – not to mention the effects HZV can have on the eye.
The best treatment is prevention, and this vaccine can play a role. So, just like we educate our patients on the myriad risks to their vision, I’m going to try to talk to my patients about zoster and getting vaccinated.
References:
Albrecht MA, et al. Vaccination for the prevention of shingles (herpes zoster). UpToDate. Updated March 23, 2018. Accessed Sept. 6, 2018.
Albrecht MA. Vaccination for the prevention of chickenpox (primary varicella infection). UpToDate. Updated May 31, 2018. Accessed Sept. 6, 2018.
Albrecht, MA. Clinical manifestations of varicella-zoster virus infection: Herpes Zoster. UpToDate. Updated Aug. 27, 2018. Accessed Sept. 6, 2018.
Krachmer JH, et al. Cornea. St. Louis, Mo.: Mosby/Elsevier; 2011.
Longo DL, et al., eds. Harrison's Principles of Internal Medicine, 18th edition. New York, N.Y.: McGraw-Hill; 2012.