• Written By: Damien Luviano, MD, FACS; Emily Weinberg, BS, PA-S
    Cornea/External Disease

    In this policy statement, the Academy offers recommendations for herpes zoster vaccine in patients aged 50 years and older.

    Study design

    Investigators compared the results of 2 randomized controlled trials involving immunocompetent patients. One trial assessed the effectiveness of the zoster vaccine live (ZVL; Zostavax), while another trial looked at the effectiveness of the recombinant zoster vaccine (RZV; Shingrix) that contains a recombinant varicella zoster virus reconstituted in a liposome-based adjuvant. The 2-dose RVZ vaccine is administered intramuscularly 2 to 6 months apart.


    One trial showed that ZVL decreased the incidence of herpes zoster and postherpetic neuralgia decreased 51% and 66%, respectively, in immunocompetent individuals aged 60 years or older. Based on this study, ZVL was approved by the FDA in 2006 and recommended by the CDC in 2008 for immunocompetent people 60 years and older. In 2011, the FDA expanded their approval of the vaccine to include immunocompetent people 50 to 59 years of age.

    By contrast, a separate trial showed that RZV had an efficacy of 97% against herpes zoster in those over age 50, and an efficacy of 90% in people older than 70 years. The RZV was approved by the FDA in October 2017 for adults 50 years of age and older. 


    The RZV study had no data on the effectiveness of the vaccine on postherpetic neuralgia. There have not been any head-to-head studies comparing the efficacy of these 2 vaccines. Despite the seemingly increased efficacy of the RZV, the 2-dose schedule may cause compliance issues.

    Patients with a history of herpes zoster ophthalmicus (HZO) may have be at risk for recurrent outbreaks after the RZV and ZVL vaccines.

    Clinical significance

    Recent studies suggest the RZV offers greater and more durable protection than the ZVL. As of 2018, the CDC recommends RZV vaccination for immunocompetent adults 50 years of age and older. Providers must take into consideration the likelihood of each patient's compliance when choosing a vaccine; the ZVL vaccine may be used if compliance is a concern. Patients with a history of HZO should be thoroughly examined to make sure the disease is under control before receiving the vaccine.

    Given the low rate of ZVL vaccination, however, the Academy advises ophthalmologists to work with other members of the health care team to encourage earlier RZV vaccination. Vaccination starting at 50 years of age may reduce the burden of this disease, including chronic eye disease.