Anyone who has had shingles knows how painful the condition can be, wherever it occurs on the body. And when the disease manifests as herpes zoster ophthalmicus (HZO), it causes a special, and potentially unending, misery.
But the recent approval of a second vaccine against herpes zoster is offering ophthalmologists a golden opportunity to help patients protect their eyes from HZO. It is recommended that the new vaccine (Shingrix, GlaxoSmithKline), as well as its predecessor (Zostavax, Merck), be given to immunocompetent patients as young as age 50—a decade sooner than earlier recommendations from federal health officials.
Urgent need for immunization. Although the relative merits of the 2 vaccines can be debated, “The real problem is that people are just not getting immunized at all. The penetration is incredibly poor,” said cornea specialist Kathryn Colby, MD, PhD, at the University of Chicago. In 2015, only 30.4% of eligible people 60 years and older were vaccinated for zoster.1
“Primary care providers don’t seem to understand the need to vaccinate against herpes zoster, so it’s good for ophthalmologists to educate patients on the benefit—because we’re the ones who will end up managing the complications. We need to get the word out, period,” said Dr. Colby.
Another cornea specialist, Francis W. Price Jr., MD, said he urges fellow ophthalmologists to advise their patients to protect their vision by getting vaccinated. “I tell my patients that getting shingles in your eye is one of the worst things that can happen to an eye,” said Dr. Price, of Price Vision Group in Indianapolis. “Chronic pain from shingles can occur from scarring around the nerve. It can literally go on for the rest of their lives.”
Recommendations. The FDA approved Shingrix last October with an indication for patients 50 years and older. Shortly afterward, the federal Advisory Committee on Immunization Practices (ACIP) voted to recommend the following:
- Shingrix should be used preferentially over Zostavax, because of clinical trial evidence that the new vaccine is more effective (a > 90% decrease in zoster incidence in all age groups, versus a 70% decrease with Zostavax in people 50-59 years old and 51% in people ≥ 60 years).
- All immunocompetent Americans age 50 and older should be immunized with the new vaccine.
- Patients should receive Shingrix even if previously immunized with Zostavax, as evidence shows that the latter’s effectiveness wanes within a few years.
Impact on the eye. Recognition of shingles’ potential to cause serious disease, pain, and complications in nonelderly patients has led several medical societies, including the Academy, to recommend that all adults be immunized against herpes zoster beginning at age 50.2 Some 1.2 million new zoster cases occur each year in the United States; of these, about 20% are HZO.2
Complications. Complications of ocular shingles include anterior and posterior segment disease; neurotrophic ocular surface disease; eyelid malpositioning/scarring; and irreversible vision loss due to corneal opacification, glaucoma, and retinal disease.
Dr. Price said that, in his experience, shingles lesions anywhere on the face or head put the patient at risk for HZO. “The textbooks generally say that you get shingles in the eye when you have an outbreak on the tip of your nose. But I’ve been doing this for over 30 years, and I have seen HZO after lesions located anywhere on the face and head,” he said.
What about cost? The Shingrix vaccine requires 2 doses, at least 8 weeks apart, and initially patients may find that insurance coverage of the estimated $280 total cost is spotty. “But I tell patients that if you’ve ever known anybody who’s had shingles, you’d go out and get vaccinated, whether insurance pays for it or not,” Dr. Price said.
1 Williams WW et al. MMWR Surveill Summ. 2017;66(11):1-28.
2 aao.org/clinical-statement/recommendations-herpes-zoster-vaccine-patients-50-. Accessed Dec. 13, 2017.
Relevant financial disclosures—Drs. Colby and Price: None.
For full disclosures and disclosure key, see below.
More from this month’s News in Review