Epidemiology of Herpes Zoster Ophthalmicus: Recurrence and Chronicity

Herpesvirus Infections of the Corneal Endothelium

Corneal endotheliitis is an inflammatory process, most commonly of viral etiology, that manifests clinically with features including corneal edema, keratic precipitates, and a mild anterior chamber reaction. Several studies have implicated human herpesviruses from the Herpesviridae family as primary causes of corneal endotheliitis, including cytomegalovirus (CMV), varicella zoster virus (VZV), and herpes simplex viruses 1 and 2 (HSV-1 and HSV-2). This review critically evaluates the present literature surrounding herpesvirus infections of the corneal endothelium.

A population-based study of social demographic factors, associated diseases, and herpes zoster ophthalmicus in Taiwan

Introduction

Herpes zoster ophthalmicus (HZO) occurs due to the reactivation of latent varicella-zoster virus (VZV) and is characterized by the involvement of the ophthalmic branch of the trigeminal nerve. While this pathophysiology is well-established, the precise mechanisms driving VZV reactivation remain incompletely understood. Furthermore, it is unclear whether individuals with common comorbidities that compromise immune function face an elevated risk of developing HZO. Investigating potential links between HZO and chronic systemic conditions holds significant importance from public health, medical, and scientific perspectives. To address these gaps, we conducted a study to examine the association between HZO development, sociodemographic factors, and systemic comorbidities.

Materials and methods

This nationwide, population-based, retrospective, matched case-controlled study included 52,112 patients with HZO (identified by the International Classification of Diseases, Ninth Revision, Clinical Modification code 053.2 for herpes zoster with ophthalmic complications) from the Taiwan National Health Insurance Research Database. The age-, sex-, and index date-matched control group included 52,112 non-HZO individuals from the Taiwan Longitudinal Health Insurance Database 2000. Sociodemographic factors and associated systemic diseases were examined using univariate logistic regression analyses, and continuous variables were analysed using paired t-tests. The odds ratios (ORs) for developing HZO were compared using adjusted logistic regression analysis.

Results

Patients with systemic diseases (hypertension, diabetes, hyperlipidaemia, etc.) had significantly higher ORs for HZO development. Patients whose monthly income was >NT$ 30,000 and patients residing in southern Taiwan had increased odds of developing HZO; however, patients residing in northern Taiwan, metropolitans, or satellite cities, and being public servants (military, civil, teaching staff, etc.) had decreased odds of developing HZO.

Discussion

HZO is strongly associated with hypertension, diabetes mellitus, hyperlipidaemia, coronary artery disease, chronic renal disease, and human immunodeficiency virus infection. These findings emphasise the role of systemic health in HZO risk.

Recurrence of herpetic keratouveitis following cataract surgery

PURPOSE

Herpetic eye disease (HED) is a leading cause of infectious vision loss worldwide. Cataract surgery is known to be implicated in triggering the recurrence of herpes keratouveitis. This study evaluates the current evidence on the association between HED and cataract surgery, focusing on the risk factors and potential pathogenic mechanisms and preventive strategies involved with reactivation or new-onset herpes-related keratitis, uveitis, or keratouveitis.

METHODS

A comprehensive search of databases (Cinahl, Embase, Scopus, ProQuest, Web of Science, and PubMed) was conducted to identify articles describing the association between new onset or reactivation of HED after cataract surgery up to March 2024. A total of 24 studies were included.

RESULTS

The heterogeneity of the studies precluded systematic analysis. However, the findings suggest that the herpetic recurrence rate, mainly in the form of keratitis, after cataract surgery is high (approximately 40%), mostly occurring ≤ 2 years after surgery, and can be influenced by factors such as topical corticosteroids, the quiescent time before surgery, and history of prior recurrences, and the patient's comorbidities, including diabetes and atopy. The current evidence for prescribing perioperative HED prophylaxis is of inadequate quality.

CONCLUSIONS

Available evidence suggests that herpetic recurrences tend to occur in the first two years after cataract surgery. A longer quiescent time before surgery might reduce the risk of recurrence. Prospective studies analyzing the effects of perioperative prophylaxis are needed.

Post-marketing safety surveillance for the recombinant zoster vaccine (Shingrix), vaccine adverse event reporting system, United States, October 2017-April 2024

Background

Recombinant zoster vaccine (RZV), received its first marketing authorization in October 2017 to prevent herpes zoster and its complications in older adults. The purpose of this study was to provide comprehensively worldwide post-marketing safety information about RZV using data from the Vaccine Adverse Event Reporting System (VAERS).

Methods

We searched for and analyzed adverse event (AE) reports of RZV submitted to U.S. VAERS between October 20, 2017 and April 26, 2024. Descriptive analyses included sex, age, time-to-onset, seriousness, most commonly reported AEs, AE of special interest, and cause of death. The empirical Bayesian data mining was employed to identify potential disproportionalities in reporting.

Results

During the study period, 1,279,596 AE reports for vaccines were received by VAERS after excluding any duplicates, including 66,849 reports specifically related to RZV. Most reports were classified as non-serious (97.3 %). Among reports with age or sex reported, individuals were mainly 50-79 years (71.2 %) and females (63.1 %). The most commonly reported AEs included injection site reactions, pyrexia, chills, headache and fatigue. A total of 86 reports documenting deaths were identified following RZV vaccination. In addition to cardiovascular events and falls, Guillain-Barre syndrome was the most common cause of death. The median TTO for RZV-related AEs was 1 day in all cohort groups over 50 years old.

Conclusion

The safety profile of RZV, based on the large sample post-marketing use, was reassuring and consistent with that observed in clinical trials. Further studies are needed to continue generating real-world safety data and further characterize RZV-AE pairs systematically.

Risk Factors for the Development of Ocular Complications in Herpes Zoster Ophthalmicus and Zoster Vaccine Utilization in a Large, Urban Health System

PURPOSE

To characterize the epidemiology of herpes zoster (HZ) and herpes zoster ophthalmicus (HZO) in an urban hospital system and determine risk factors associated with developing ocular complications in HZO. To report the frequency of shingles vaccination and HZ reactivation following shingles vaccination in this population.

METHODS

A retrospective cohort study was conducted on patients seen at the University of Illinois Hospital system from January 1, 2010 to December 1, 2021 with HZ and HZO identified by diagnosis code. Charts of HZO patients seen within 1 year of diagnosis were abstracted. Multivariable logistic regression analysis identified factors associated with the development of ocular complications in HZO.

RESULTS

During the study period, 3283 patients had HZ; mean age of onset was 52.3 years, 61.6% were female, and 37% were Black. HZO with ocular involvement was seen in 110 (3.4%) patients. Ocular complications developed in 40 (36.4%) patients; the most common complication was corneal scarring (70%). Age (odds ratio [OR] 1.04, 95%CI 1.0-1.1), female gender (OR 2.86, 95%CI 1.0-8.1), steroids at initial visit (4.46, 95%CI 1.4-14.6), and stromal keratitis (OR 3.45, 95% CI 1.2, 9.8) were associated with developing ocular complications. Of eligible populations, 5333 (1.5%) received shingles vaccination; 43 patients developed reactivation of HZ following vaccination.

CONCLUSIONS

In HZO, age, female gender, steroids at initial visit, and stromal keratitis are strongly associated with developing ocular complications. Shingles vaccination rates were low in this study population. Understanding potential for complications in HZ/HZO and vaccination uptake can help identify at risk populations to prevent disease. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Herpes zoster ophthalmicus temporally after COVID-19 vaccination: a systematic review of uncontrolled case reports and case series

Purpose

Herpes zoster ophthalmicus (HZO) following COVID-19 vaccination has been reported previously but the clinical characteristics, onset, treatment, and outcomes of these cases have not been previously systematically reviewed.

Methods

A systematic review, guided by PRISMA guidelines, surveyed PubMed and Embase databases from April 2021 to June 2023 for case reports and series detailing HZO following COVID-19 vaccination. Studies excluded were abstracts, reviews, and clinical trials. A subsequent descriptive analysis was performed, focusing on patient demographics, clinical characteristics, and outcomes.

Results

Sixteen publications involving 27 participants who developed HZO post-COVID-19 vaccination met the inclusion criteria. The onset of HZO averaged 13 days (SD 12) postvaccination, predominantly after the first dose (n = 20/27 HZO cases, 74%). Most patients (70%) had preexisting medical conditions. Antiherpetic antiviral therapy was utilized in all cases, with the majority achieving resolution of cutaneous and ocular symptoms. Long-term sequelae included postherpetic neuralgia in 7.4% of patients.

Conclusion

Cases of HZO following COVID-19 vaccination generally mirror the clinical trajectory of HZO in general. This review focused on case reports describing HZO occurring in an interval postvaccination; neither association nor causation can be addressed methodologically.

Herpes Zoster Ophthalmicus Uveitis: Onset and Complications

PURPOSE

To describe the timing of uveitis onset and frequency of associated complications in individuals with herpes zoster ophthalmicus (HZO).

DESIGN

Retrospective, cohort study.

METHODS

Individuals with acute HZO seen at the Auckland District Health Board from 2006 to 2016 were studied. The primary outcome measures were the proportion who developed uveitis and time to diagnosis of uveitis following the onset of HZO. Secondary outcome measures included complications of HZO uveitis and effects of prompt antiviral (within 72 hours) on outcomes.

RESULTS

A total of 869 patients with HZO were included for analysis, of whom 413 (47.6%) developed uveitis. Median time from onset of rash to diagnosis of uveitis was 10 days (IQR 6-14). Of the 658 individuals examined within the first week following rash onset (days 0 through 7), 17.6% (116/658) were diagnosed with uveitis at that initial presenting examination, with an additional 24.9% (164/658) diagnosed with uveitis at a subsequent visit. Complications were higher in eyes with uveitis, including moderate or severe vision loss, corneal scarring, neurotrophic keratitis, band keratopathy, corneal melt, elevated intraocular pressure, glaucoma, and cataract (all P < .01). Prompt antiviral was associated with a lower rate of moderate vision loss among eyes with uveitis (P = .02).

CONCLUSIONS

Uveitis occurred in approximately half of individuals with HZO and was most frequently diagnosed during the second week following rash onset. Eyes with uveitis were more likely to have other ocular complications and loss of vision.

Herpes Zoster Ophthalmicus Recurrence: Risk Factors and Long-Term Clinical Outcomes

PURPOSE

To examine the frequency of recurrences, risk factors, and long-term clinical outcomes in subjects with herpes zoster ophthalmicus (HZO).

DESIGN

Retrospective cohort study.

METHODS

All subjects with acute HZO seen at a single center from 2006 to 2016 were included in the study. The primary outcome measure was eye disease recurrence. The secondary outcome measure was moderate vision loss (≤20/50).

RESULTS

A total of 869 patients with acute HZO were identified, with a median follow-up time of 6.3 years (interquartile range 3.7-8.9 years). In all, 551 recurrences were observed, and at least 1 recurrence was seen in 200 subjects (23.0%), with uveitis (34.8%) being the most common. The median time to first recurrence was 3.5 months. Predictors of disease recurrence included immunosuppression (P = .026), higher presenting intraocular pressure (P = .001), corneal involvement (P = .001), and uveitis (P < .001) on multivariate analysis. Topical steroids were initiated in the first month of presentation in 437 subjects, and recurrence was observed in 184 (42.1%) of these subjects. Following cessation of topical steroid treatment, recurrence occurred after a median of 1.4 months (90% within 7 months). Moderate vision loss (≤20/50) occurred in 15.5%, 28.6%, 31.4%, 50.0%, and 57.4% of eyes with 0, 1, 2, 3, and 4 or more recurrences.

CONCLUSIONS

Recurrence of HZO eye disease is common, with an increased risk of vision loss with more recurrences. These findings indicate the need for close monitoring for potential recurrences, especially after cessation of topical steroid treatment, and in individuals with identified risk factors for recurrence.

Changing age pattern and diverse outcomes of herpes zoster ophthalmicus: exploring the temporal trend, decrease in incident age and influence of treatment strategies

PURPOSE

Herpes Zoster Ophthalmicus (HZO) is a disease commonly affecting the elderly and immunocompromised. Over the last several years, a trend towards decreasing incident age, albeit with varying clinical features, has been observed. This temporal trend towards the younger age group necessitates a detailed evaluation to determine possible causes of its occurrence in this population.

METHOD

This is a hospital-based retrospective study. 154 datasheets were initially identified. After excluding non-relevant data sheets (88), 56 relevant and complete records were subjected to comprehensive analysis in adherence to the inclusion criteria.

RESULTS

Most commonly affected age group was < 40 years, with the mean age being 38. Conjunctivitis was the most frequent occurrence seen in 82.05%. Keratitis was seen in varying forms as, epithelial (64.44%), stromal (15.3%) & nummular (3.57%). Anterior uveitis in 35.89%, posterior uveitis (retinitis, neuro-retinitis) in 7.69% of cases, posterior segment involvement (rhegmatogenous retinal detachment, optic atrophy) in 8.8%, secondary glaucoma in 28.2%, optic neuritis in 5.3% while orbital apex and cavernous sinus involvement were seen in one case.

CONCLUSION

This study reflects a temporal shift in the incidence of HZO towards the younger age group. The proportion of younger patients with HZO is increasing with some male preponderance. Identifiable factors contributing to potential risk, recurrence, and chronicity of HZO are related to demographics, immune status, dietary, environmental associations, vaccination status, and previous history of recurrences. Reported outcomes can be valuable in understanding the evolving patterns of HZO and improving patient care, public health and vaccination policies.

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

Herpes zoster (HZ) is caused by reactivation of latent infection of varicella zoster virus (VZV) in sensory (cranial, dorsal root) ganglia. Major risk factors for HZ are increasing age and immunosuppression. HZ ophthalmicus (HZO) is a subset of HZ with involvement of the ophthalmic division of the fifth cranial trigeminal nerve. Approximately 4-20% of patients with HZ develop HZO. Approximately 50% of patients with HZO develop ocular disease, among whom up to 25% develop chronic or recurrent disease. Common manifestations of ocular disease include conjunctivitis, keratitis, and uveitis, whereas optic neuropathy and retinitis are uncommon. Due to the potential for vision impairment, ocular involvement requires urgent ophthalmic consultation. Early recognition and timely treatment with antivirals may prevent ocular complications. HZO is preventable by vaccination against HZ. Vaccine efficacy/effectiveness studies have been largely conducted for HZ with few studies assessing HZO. Both the recombinant adjuvanted vaccine (RZV) and live-attenuated vaccine (ZVL) significantly reduce the incidence of HZ and HZO in older adults. RZV is more effective than ZVL. Data on the effectiveness of vaccines for prevention of recurrent disease in patients with HZO are limited; however, vaccination is recommended. Despite recommendations to vaccinate individuals likely to benefit from an HZ vaccine, coverage for adults remains suboptimal. Barriers to vaccination include patient beliefs about HZ or HZ vaccines, and factors related to healthcare providers. In particular, the lack of a recommendation from their primary care physician is often cited by patients as a reason for remaining unvaccinated. By encouraging vaccination against HZ, physicians not only prevent HZ and HZO but also potential vision loss due to HZO.Graphical abstract available for this article.

Clinical and demographic profile of herpes zoster ophthalmicus: A hospital-based study of 1752 Indian patients

PURPOSE

To describe the clinical and demographic profile of herpes zoster ophthalmicus (HZO) in patients presenting to a multitier ophthalmology hospital network in India.

METHODS

Cross-sectional hospital-based study included 3,004,470 new patients between August 2010 and October 2021. Patients with a clinical diagnosis of HZO in at least one eye were included. Data were collected using an electronic medical record system.

RESULTS

In total, 1,752 (0.058%) patients were diagnosed with HZO. Nearly two-thirds were male (63.76%) in the seventh decade of life (339;19.35% patients) with unilateral (98.34%) affliction. Higher prevalence was seen in patients from higher socioeconomic status (0.059%) and metropolitan geography (0.062%). Most common ocular signs included eyelid edema (44.19%), conjunctival congestion (65.69%), punctate keratopathy (23.36%), and anterior uveitis (21.22%). Of the 1,781 eyes, mild/no visual impairment was seen in 952 (53.45%) eyes, moderate in 258 (14.49%) eyes, and severe to blindness in 363 (20.39%) eyes. Oral antivirals were started within 72 h (Group A) in 361 (20.61%) patients and after 72 h in 1391 (79.39%) patients (Group B). Significantly lesser severity of ocular involvement was noted in Group A ( P < 0.00001). Surgical intervention was required in 211 (11.85%) eyes.

CONCLUSION

HZO more commonly affects males in the seventh decade of life and is predominantly unilateral. It more commonly affects those from higher socioeconomic strata and metropolitan regions. Half of the eyes have mild or no visual impairment, while others have moderate to severe impairment. Institution of antivirals within 72 h is associated with less severe involvement. Surgical intervention is warranted in a tenth of the eyes.

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus (HZO) occurs when latent varicella zoster virus reactivates in the ophthalmic division of the fifth cranial nerve (CNV1). HZO commonly affects older and immunocompromised patients. This disease is considered an ophthalmic emergency due to the wide range of associated ocular symptoms, including severe chronic pain and vision loss. HZO is typically a clinical diagnosis due to its classic presentation of a unilateral vesicular eruption in the dermatomes corresponding to CNV1. Timely treatment is imperative to minimize ocular morbidity in HZO, given that ocular involvement is present in 50% of affected patients.

Herpes Zoster Chorioretinopathy: A Case Series

PURPOSE

To report two patients with herpetic zoster panuveitis and chorioretinopathy with choroidal hypopigmentation.

METHODS

Retrospective chart review of two patients.

RESULTS

We report a series of two patients with a history of HZO with orbital inflammation and panuveitis, who developed patchy choroidal depigmentation consistent with a choroidopathy. The lesions were extensive and involved the posterior pole and mid-periphery in both cases. Both cases demonstrated scattered areas of ellipsoid zone loss, and fluorescein angiography showed corresponding late hyperfluorescence. OCTA in one case demonstrated flow voids at the level of choriocapillaris.

CONCLUSIONS

Our series suggests that herpetic chorioretinopathy may be a relatively benign process that presents late and may involve large areas of the posterior choroid.

Risk of Herpes Zoster Ophthalmicus Recurrence After Recombinant Zoster Vaccination

Importance

The recombinant zoster vaccine (RZV) is currently recommended for immunocompetent adults aged 50 years or older and immunocompromised adults aged 19 years or older and is effective in preventing herpes zoster ophthalmicus (HZO). However, questions about the safety of RZV in patients with a history of HZO remain.

Objective

To evaluate whether there is an increased risk of HZO recurrence after RZV in patients with a history of HZO.

Design, Setting, and Participants

This retrospective cohort study used medical and outpatient pharmacy claims data for commercial and Medicare Advantage enrollees from the Optum Labs Data Warehouse. Patients with incident HZO from January 1, 2010, to December 31, 2021, were identified; the study period ended on March 31, 2022. The vaccinated group consisted of patients with at least 1 dose of RZV more than 90 days following the initial HZO diagnosis. The unvaccinated group consisted of patients without any record of RZV in the study period. Vaccinated and unvaccinated patients were matched using exact k:1 matching without replacement.

Exposure

Recombinant zoster vaccination.

Main Outcomes and Measures

The main outcome was the number of HZO recurrences with and without RZV exposure.

Results

A total of 16 408 patients were included in the matched analysis, of whom 12 762 were unvaccinated (7806 [61.2%] female; mean [SD] age at diagnosis, 68.8 [10.3] years) and 3646 were vaccinated (2268 [62.2%] female; mean [SD] age at diagnosis, 67.4 [9.8] years). Within the primary risk period of 56 days after the index date (ie, the start of follow-up for the outcome), the incidence of HZO recurrence after any RZV exposure was 37.7 per 1000 person-years compared with 26.2 per 1000 person-years in the unexposed group. After controlling for race and ethnicity, inpatient stays, emergency department visits, concomitant vaccines, and eye care practitioner visits, the association between vaccination status and HZO exacerbation in the primary risk period had an adjusted hazard ratio for any RZV exposure of 1.64 (95% CI, 1.01-2.67; P = .04).

Conclusions and Relevance

In this study, RZV exposure was associated with a higher likelihood of HZO recurrence in patients with a history of HZO compared with no RZV exposure. These findings support consideration that patients with a history of HZO may benefit from monitoring after receiving RZV in case of HZO recurrence.

Herpes Zoster Recurrence: A Narrative Review of the Literature

INTRODUCTION

Herpes zoster (HZ; shingles) is a painful, cutaneous disease caused by reactivation of the varicella zoster virus, which causes varicella (chickenpox) typically during childhood. The considerable healthcare burden of HZ is relatively well documented, with approximately one in three individuals experiencing at least one episode during their lifetime, debilitating symptoms including neuropathic pain, and complications such as post-herpetic neuralgia, vision loss, and rarely, stroke, and increased severity in immunocompromised individuals. However, we are not aware of a comprehensive review of literature specifically examining the burden of HZ recurrence.

METHODS

We conducted a PubMed search (1 January 2003-2 February 2023) to assess available literature on the incidence, risk factors, and clinical features of HZ recurrence.

RESULTS

The incidence of HZ recurrence reported by the studies identified was wide ranging. Studies in general populations of immunocompetent or immunocompetent/immunosuppressed (mixed) populations with an initial HZ episode estimate that approximately 1.2-9.6% of individuals may experience HZ recurrence, with an incidence rate of 1.7-16.6 cases per 1000 person-years. HZ recurrence was reported in 0.0-18.2% of immunocompromised individuals with HZ, with an incidence rate of 17.0-55 cases per 1000 person-years. Incidence rates varied according to study design, follow-up, and study populations. Recognized risk factors for HZ recurrence include immunocompromised status, female sex, family history, and comorbidities such as diabetes. Other factors that may predispose individuals to recurrence include long-lasting pain after the initial HZ episode and the presence of herpes zoster ophthalmicus.

DISCUSSION

Our review underlines that following an initial HZ episode, individuals remain at risk of HZ recurrence, adding to the disease burden in a population. As HZ is preventable by vaccination, national HZ vaccination recommendations should include the need for and timing of vaccination in both immunocompetent and immunocompromised individuals who have a history of HZ.

De Novo Uveitis in the Colombian Elderly Population: Characteristics and Comparison with Patients Under 60 Years of Age

PURPOSE

To describe the differences between de novo uveitis in elderly patients (≥60 years of age) and younger patients (< 60 years of age) in Colombia.

METHODS

Observational, analytic, cross-sectional study.

RESULTS

In the elderly group, idiopathic was the most common type of uveitis, followed by immune-mediated and infectious uveitis.No masquerade syndromes were diagnosed. Elderly patients had worse average visual acuities than young. Significant differences between both groups were observed in corneal edema, macular edema, cataract, glaucoma, and epiretinal membrane. Additionally, there were differences in the drugs used, such as topical hypotensive drugs, ocular lubricants, topical steroids, methotrexate, hydroxychloroquine, and adalimumab.

CONCLUSION

The present study demonstrated significant differences between elderly and young Colombian patients with de novo uveitis. The ophthalmologists should be aware of these patterns of presentation, which would help reach an adequate diagnosis and prevent complications based on the characteristics of each group.

Diagnostic performance of real-time quantitative PCR in tear samples in various subtypes of herpes simplex keratitis

Diagnosis of herpes simplex keratitis (HSK) is mostly based on clinical findings, yet biological confirmation supports management of challenging cases. This study evaluated the place of real-time quantitative PCR (RT-qPCR) on tear samplings in the management of HSK. Clinical records of patients who underwent tear sampling tested by RT-qPCR for herpes simplex virus type 1 for an acute episode of corneal inflammation or defect between January 2013 and December 2021 were retrospectively reviewed, and results were compared to clinical diagnosis (i.e., HSK or not) based on biomicroscopic findings and medical history. Of 465 tested tear samples from 364 patients, a clinical diagnosis of active (ongoing) HSK was recorded in 240 cases, among which 76 were RT-qPCR positive (global sensitivity of 31.6%, specificity of 99.5%). Sensitivity of RT-qPCR was higher in epithelial (97.4%) and stromal keratitis with ulceration (48.7%), compared to other types of HSK (23.5% in keratouveitis, 13.6% in endotheliitis, 11.1% in postherpetic neurotrophic keratopathy, and 8.1% in stromal keratitis without ulceration). The highest viral loads were detected from epithelial and stromal keratitis with ulceration, while in HSK with no epithelial involvement, the viral load detected was 196-fold lower, on average. The proportion of clinically characterized HSK patients with negative tear samples was higher in patients receiving antiviral treatment (P < 0.0001). RT-qPCR, performed on tear samples, can help in confirming diagnosis in case of presumed HSK, including clinical forms with no obvious epithelial involvement. The sensitivity of tear sampling is much higher whenever epithelial keratitis is present.

Herpes Zoster Ophthalmicus With Dacryoadenitis Complicated by Recurrent Orbital Inflammation

Herpes zoster ophthalmicus represents a zoster infection in the first division of the trigeminal nerve and has potentially serious complications involving the ocular and orbital structures. Herpes zoster ophthalmicus occurs in approximately 10% to 20% of individuals with herpes zoster and can lead to significant morbidity, particularly in patients with multiple comorbidities. The authors present a case of herpes zoster ophthalmicus along with dacryoadenitis in a patient with uncontrolled diabetes and rheumatoid arthritis who was misdiagnosed, had delayed treatment, and experienced recurrence with orbital symptoms during follow up. Prompt recognition, initiation of therapy and careful monitoring and follow up are important for treating herpes zoster ophthalmicus and preventing recurrence and long-term sequelae.

Approaching headaches and facial pains in eye care practice

Headaches and facial pains are among the most frequent ailments seen in outpatient or emergency settings. Given the fact that some of the primary headaches and facial pains mimic the characteristic patterns seen in ocular diseases and related conditions, it is fairly common for these situations to be sent to an ophthalmology or optometry clinic and misdiagnosed as ocular headaches. This may result in a delay in starting an appropriate therapy, therefore extending the patient's illness. This review article aims to help the practitioners in understanding common causes of headaches and facial pains, approaching such cases in eye OPD and differentiating them for similar ocular conditions to impart an appropriate treatment or referral.

Increasing Rates of Herpes Zoster Ophthalmicus and the COVID-19 Pandemic

Purpose

This epidemiologic study evaluates the variance in incidence of Herpes Zoster (HZ) and Herpes Zoster Ophthalmicus (HZO) within a single healthcare system with an aim to analyze their relationship to the COVID-19 pandemic.

Methods

All patients attending the Duke University Health System (DUHS) from January 1, 2018, to December 31, 2021, were included. General and COVID-related trends of HZO and HZ were analyzed based on new ICD-9 or ICD-10 diagnosis codes, compared with the total number of patients seen at DUHS during this period, and the number of reported COVID-19 cases in North Carolina obtained using the CDC data tracker.

Results

This study included 16,287 cases of HZ of whom 1,294 (7.94%) presented with HZO. The overall incidence of HZO showed an average yearly increase of 5.6%, however HZ incidence decreased by 5.3% per year. When comparing incidence rates of HZO in the 12-months before and after the COVID-19 pandemic onset in the United States (March 2020), the average incidence from March 2020 to February 2021 was 27.6 ± 11.6 compared to 18.0 ± 2.7 from March 2019 to February 2020 (p = 0.01). Moreover, 10/12 (83.3%) of the months had a higher incidence rate of HZO in the post-COVID onset year compared to their corresponding month in the pre-COVID year.

Conclusion

The results show HZO incidence may be increasing, despite an overall lower HZ incidence. This could suggest a distinct mechanism for HZO appearance. The COVID pandemic, directly or indirectly, may have accelerated the already increasing HZO incidence.

A Case of Herpes Zoster Ophthalmicus With Multiple Delayed Ocular Complications

Herpes zoster ophthalmicus (HZO) presents a variety of ocular complications, most of which occur simultaneously as skin lesions. We report a case of HZO with delayed onset of multiple ocular complications. A 72-year-old man developed HZO, blepharitis, iritis, and conjunctivitis in the left eye, which resolved after topical ocular treatment and systemic acyclovir administration. However, six weeks after the first onset of the rash, the patient came to our hospital because of recurrent blepharitis, iritis, scleritis, conjunctivitis, eye pain, ptosis, and blurred vision in the left eye. Best corrected visual acuity (BCVA) in the left eye had decreased to hand motion, and the Goldmann visual field test showed only mild residual peripheral vision on the lateral side. Intraocular pressure showed 25 mmHg in the left eye and inflammation in the anterior chamber with paralytic mydriasis. Orbital magnetic resonance imaging (MRI) showed the contrast effects with the lacrimal gland, superior ophthalmic vein, supraorbital nerve, optic nerve, and around optic nerve sheath. The patient was diagnosed with optic neuritis, optic perineuritis, ptosis, paralytic mydriasis, trigeminal neuralgia, lacrimal gland inflammation, blepharitis, iritis, scleritis, and ocular hypertension after HZO, and three courses of steroid pulse therapy were administered. Thereafter, BCVA improved to 0.3 in the left eye, with improvement in central vision, and MRI lesions and other symptoms also improved. The patient has had no complications or recurrence of HZO. HZO can cause a variety of ocular complications. Since autoimmune mechanisms might be involved, combined immunotherapy should be considered.

Herpes simplex virus, varicella-zoster virus and cytomegalovirus keratitis: Facts for the clinician

Keratitis due to Herpes simplex virus (HSK), Varicella-Zoster virus (VZK) and Cytomegalovirus remains a frequent source of concern for many ophthalmologists. They are a frequent cause of emergency consultations at eye care centers and carry the risk of permanent loss of visual acuity or visual quality and/or chronic neurotrophic keratitis, resulting in a significant decrease in the quality of life. HSK and VZK can affect the corneal epithelium, stroma, or endothelium or a combination of layers. In contrast, most cases of CMV keratitis present as isolated endothelitis (CMVE), a clinical entity that has been described within the last 2 decades. These three types of viral keratitis are characterized by a high frequency of recurrences and each new episode increases the risk of sequelae. Hence, ophthalmologists must adapt the treatment to the clinical presentation of each recurrent episode in order to mitigate the immediate consequences of viral replication and the immune response on corneal transparency. In patients with frequent recurrences, preventive long-term antiviral treatment is strongly recommended. However, in some rare cases, continuous exposure to antivirals may promote the emergence of resistant viral strains, which can be difficult to manage. In the future, the introduction of new antiviral drugs, with differing modes of action compared to current medical therapy, could be an alternative until a truly effective preventive solution, such as a vaccine, is available.

Clinical Manifestations and Long-term Outcomes of Endothelial Keratoplasty in Patients with Proven VZV-related Endothelial Decompensation

PURPOSE

To report the clinical manifestations, postoperative complications and long-term outcomes of endothelial keratoplasty in VZV-related endothelial decompensation.

METHODS

In this retrospective study, thirteen eyes undergoing endothelial keratoplasty (EK) for VZV-related endothelial decompensation were compared with controls for Fuchs endothelial dystrophy or pseudophakic bullous keratopathy.

RESULTS

Twelve patients did not have typical dermal pain or blisters. Ten patients had obvious iris abnormalities. Glaucoma was noted in eight patients before surgery. The best spectacle-corrected visual acuity improved from 1.12 ± 0.47 to 0.39 ± 0.43 (p = .002), whereas endothelial cell (EC) loss was 65% ±15% at 12 months that higher than that in the controls (p < .05). Postoperative complications included graft detachment (2/13), recurrence of endotheliitis (3/13), neurotrophic ulcer (1/13) and scleritis (1/13).

CONCLUSIONS

The onset of VZV-related endothelial decompensation is generally insidious. Iris segmental atrophy, glaucoma and pigment KPs are highly suspected to be associated with VZV. EK is a reasonable option to rehabilitate vision.

A Guide to Preclinical Models of Zoster-Associated Pain and Postherpetic Neuralgia

Reactivation of latent varicella-zoster virus (VZV) causes herpes zoster (HZ), which is commonly accompanied by acute pain and pruritus over the time course of a zosteriform rash. Although the rash and associated pain are self-limiting, a considerable fraction of HZ cases will subsequently develop debilitating chronic pain states termed postherpetic neuralgia (PHN). How VZV causes acute pain and the mechanisms underlying the transition to PHN are far from clear. The human-specific nature of VZV has made in vivo modeling of pain following reactivation difficult to study because no single animal can reproduce reactivated VZV disease as observed in the clinic. Investigations of VZV pathogenesis following primary infection have benefited greatly from human tissues harbored in immune-deficient mice, but modeling of acute and chronic pain requires an intact nervous system with the capability of transmitting ascending and descending sensory signals. Several groups have found that subcutaneous VZV inoculation of the rat induces prolonged and measurable changes in nociceptive behavior, indicating sensitivity that partially mimics the development of mechanical allodynia and thermal hyperalgesia seen in HZ and PHN patients. Although it is not a model of reactivation, the rat is beginning to inform how VZV infection can evoke a pain response and induce long-lasting alterations to nociception. In this review, we will summarize the rat pain models from a practical perspective and discuss avenues that have opened for testing of novel treatments for both zoster-associated pain and chronic PHN conditions, which remain in critical need of effective therapies.

Neurotrophic Keratopathy After Herpes Zoster Ophthalmicus

PURPOSE

The aim of this study was to describe risk factors for neurotrophic keratopathy (NK) after herpes zoster ophthalmicus (HZO).

METHODS

This study was a retrospective review of all patients seen at the Auckland District Health Board with HZO from 2006 through 2016. Cox proportional hazards analysis was performed to examine time to development of neurotrophic keratitis.

RESULTS

Eight hundred sixty-nine patients were included in the study with a median follow-up of 6.3 years (5504.4 patient-years). The median age was 65.5 years (interquartile range 52.9-75.4), and 456 subjects (52.5%) were male. NK developed in 58 patients (6.7%), with the highest hazard 1 to 2 years after onset of HZO. On univariate analysis, age, White ethnicity, best-corrected visual acuity (BCVA) at presentation, intraocular pressure, corneal involvement, uveitis, and number of recurrences were associated with increased risk of NK. On multivariate analysis, the following factors were significant: age (hazard ratio [HR] = 1.03; P = 0.021), White ethnicity (HR = 3.18; P = 0.015), BCVA (HR = 1.81; P = 0.026), uveitis (HR = 3.77; P = 0.001), and recurrence (HR = 1.34; P < 0.001). Vision loss (BCVA ≤6/15) was more frequent in subjects with NK (65.5% vs. 16.3%, P < 0.001).

CONCLUSIONS

NK is a relatively common and serious complication of HZO and occurs more frequently in older White individuals, those with poor visual acuity at presentation, and those with uveitis. Vision loss occurs in approximately two-thirds of patients.

Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2

Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.

Recurrence of Varicella-Zoster Virus Keratitis After SARS-CoV-2 Vaccination

PURPOSE

The purpose of this study was to report a case of acute exacerbation in varicella-zoster virus (VZV) keratitis after SARS-CoV-2 vaccination.

METHODS

An 87-year-old man, with a history of herpes zoster ophthalmicus 10 years ago, was referred for sudden visual impairment in his left eye that started 2 days after his second dose of SARS-CoV-2 mRNA vaccine BNT162b2.

RESULTS

At presentation, his visual acuity was hand motion. Slitlamp examination revealed diffuse corneal stromal edema and nasal stromal infiltration. After treatment for 2 weeks with oral valacyclovir and topical corticosteroids, the problematic lesion was recovered and his visual acuity was restored to 20/30.

CONCLUSIONS

We believe that this is the first report of possible association between recurrence of VZV keratitis and SARS-CoV-2 vaccination. We believe that T-cell activation by the host response after vaccination may affect the recurrence of VZV keratitis. Physicians should be aware of the potential of recurrence of VZV keratitis associated with the SARS-CoV-2 messenger RNA vaccine.

Ophthalmic herpes zoster with severe complications in an immunocompromised patient: A case report and review of the literature

The increasing incidence for herpes zoster, including its ophthalmic form, is based on physiological (senescence) and acquired immunosuppression, particularly under oncologic treatment. The immunocompromised status of the patient favors the appearance of severe complications. The patient, aged 54, with chronic lymphocytic leukemia, presented 1 week from the onset with an erythematous, vesicular-bullous rash on the right trigeminal nerveʼs ophthalmic dermatome, marked edema, intense pain and large submandibular ganglion masses. There were cutaneous (necrotic ulcerations superinfected with methicillin-resistant Staphylococcus aureus), ocular (keratoconjunctivitis, total ophthalmoplegia, lagophthalmia, anterior hemorrhagic uveitis with hyphema and right eye blindness) and neurological (postherpetic neuralgia) complications. Systemic therapy was performed with acyclovir, antibiotics, supportive, rebalancing and symptomatics. With regards to treatment for skin ulcers, disinfection and necrectomy were performed, and epithelialization agents were subsequently administrated. At the ocular level, the ophthalmologist carefully monitored the patient and administered antivirals, antibiotics, epithelialization agents and autologous serum. The evolution of the case recorded severe, disabling complications, with extensive eyelid necrosis and definitive blindness. In this case, the severity of the ophthalmic herpes zoster (OHZ) was favored by the synergistic action of four factors: Acquired immunosuppression (chronic lymphocytic leukemia), delayed consultation, superinfectious lesions and patient non-compliance regarding the chronic lymphocytic leukemia treatment.

EYE DISEASE IN KIDNEY TRANSPLANTATION: CLINICAL CHALLENGES IN A UNIQUE PATIENT POPULATION

Eye disease is common among kidney transplant recipients and their management is challenging. Chronic kidney disease is associated with ocular complications, both independently and in the context of various systemic disorders. In addition, chronic immunosuppression predisposes kidney transplant recipients to an array of long-term ocular issues. This may be broadly categorized into infections, malignancies, and other immunosuppression-specific side effects. The interdependence of kidney disease, transplant pharmacotherapy and ocular health therefore requires a multispecialty approach. Although the kidney transplant population has grown along with the burden of associated oculopathies, systematic guidelines targeting this patient group are lacking. This evidenced-based narrative review summarizes the pertinent issues that may present in the ophthalmic and optometric clinical settings, with emphasis on collaborative management and directions for future research.

Colombian Ocular Infectious Epidemiology Study (COIES): Herpes Zoster Ophthalmicus prevalence and sociodemographic characterization, 2015-2019

OBJECTIVES

This study aimed to estimate the prevalence of Herpes Zoster Ophthalmicus (HZO) and describe the sociodemographic disease distribution by age, sex, and region in Colombia using National Health Registry data between January 1, 2015, to December 31, 2019.

METHODS

We conducted a cross-sectional study using the Integrated Social Protection Information System database from the Colombian Ministry of Health, the unique official database in the country. We used the specific code of the International Classification of Diseases for HZO (B02.3) from 2015-2019 to estimate the prevalence and the demographic status of the disease in Colombia.

RESULTS

The average prevalence was 0.99 in 100,000 inhabitants. Females represented 54.44% of the cases from 2.378 included patients. The distribution by age has a continual increasing distribution from the quinquennial age group of 55 years. The geographic analysis shows a higher disease burden in the Andean region, followed by the Caribbean and Pacific regions.

CONCLUSION

This is the first study that determines the HZO epidemiological characteristic based on a National Health database in our region. We found an age distribution similar to previous studies and bore out that higher altitudes correlate with a higher burden of the disease.

Chronic and Recurrent Herpes Zoster Ophthalmicus

Background and Objectives: This study sought to investigate the natural course, the chronicity and recurrence rate, and the risk factors of chronic and recurrent herpes zoster ophthalmicus (HZO). We also evaluated the effects of long-term treatment for HZO. Materials and Methods: Patients diagnosed and treated for HZO were included in the retrospective medical chart review. Multivariable-adjusted logistic and Cox regression models were used to show risk factors for chronic and recurrent HZO along with hazard ratios (HRs) and 95% confidence intervals (CIs). Results: Among a total 130 of HZO patients, 31 patients (23.85%) had chronic disease and 19 patients (14.62%) had recurrent disease. The rate of chronic disease was higher in HZO with conjunctivitis, epithelial keratitis, and stromal keratitis. The recurrence rate increased in patients with chronic HZO (HR: 34.4, 95% CI: 3.6–324.6), epithelial keratitis (HR: 5.5, 95% CI: 1.3–30.0), stromal keratitis (HR: 18.8, 95% CI: 3.0–120.8), and increased intraocular pressure (IOP) (HR: 7.3, 95% CI: 1.6–33.2). Length of systemic antiviral therapy and anti-inflammatory eyedrop treatment were not associated with recurrent HZO (p = 0.847 and p = 0.660, respectively). The most common ocular manifestation for recurrent HZO was stromal keratitis. Conclusions: This study demonstrated a considerable frequency of chronic and recurrent HZO. Chronic HZO in the form of epithelial or stromal keratitis with increased IOP provoked a significant rise in the risk of recurrence.

Ipsilateral Zoster Ophthalmicus Post COVID-19 Vaccine in Healthy Young Adults

Herpes zoster ophthalmicus (HZO), which is an ophthalmological emergency, accounts for 10%-20% of all Herpes zoster (HZ) cases. HZ infection in COVID-19 vaccinated individuals who are immunocompetent can be attributed to vaccine-induced immunomodulation allowing the varicella-zoster virus (VZV) to escape from the dorsal root ganglia. Another theory is similar to immune reconstitution syndrome (IRS). HZ infection in a young immunocompetent individual is a rare entity. As per our literature review, only four cases have been reported thus far. We are reporting two cases of two young individuals with no known risk factors who developed ipsilateral HZO after receiving the COVID-19 vaccination. The increasing incidence of HZ cases post COVID-19 vaccine indicates that this is not a mere coincidence. Awareness must be created among physicians, as well as the general population, for early recognition and early antiviral usage, which can halt the progression of the disease and thus prevent debilitating complications.

Herpes Zoster: A Brief Definitive Review

ABSTRACT

This brief definitive review of herpes zoster (HZ) will cover the current state of knowledge and questions that remain to be answered regarding HZ in general and HZ ophthalmicus in particular. A question-and-answer format will be used to address various important topics related to this common and serious disease. Questions to be addressed relate to common misconceptions, contagiousness of infection, unknowns regarding pathogenesis, rising incidence, risk factors and complications, relationship with temporal arteritis, vaccination, and current and future antiviral treatment. In addition, the importance of the Zoster Eye Disease Study to determine the efficacy of suppressive valacyclovir treatment in preventing complications of HZ ophthalmicus and the need to support enrollment will be discussed.

Herpes Zoster Ophthalmicus Clinical Presentation and Risk Factors for Loss of Vision

PURPOSE

To determine the rate of moderate and severe vision loss following herpes zoster ophthalmicus (HZO) and to identify associated factors.

DESIGN

Retrospective cohort study.

METHODS

All subjects with acute HZO seen at a single center from 2006 to 2016 were included in the study. The primary outcome measure was the proportion of individuals with moderate and/or severe loss of vision following an acute episode of HZO. Secondary outcome measures included causes and factors associated with permanent loss of vision owing to HZO.

RESULTS

A total of 869 patients with acute HZO were identified with a median follow-up time of 6.3 years (interquartile range 3.7-8.9 years). Ocular involvement of HZO was diagnosed at or within the first month of presentation in 737 individuals (84.8%). The most common sites of ocular involvement were conjunctivitis (76.1%), followed by keratitis (51.2%) and uveitis (47.6%). Moderate vision loss (≤20/50) secondary to HZO occurred in 83 eyes (9.6%) while severe vision loss (≤20/200) occurred in 31 eyes (3.6%). Causes of loss of vision included corneal scarring (94.0%), corneal perforation (4.8%), and secondary glaucoma (1.2%). Severe vision loss was associated with older age (hazard ratio [HR] 1.059, P = .001), immunosuppression (HR 3.125, P = .028), poor presenting visual acuity (HR 2.821, P = .002), and uveitis (HR 4.777, P = .004) on multivariate analysis.

CONCLUSIONS

Among individuals with HZO, approximately 1 in 10 individuals may develop moderate or severe vision loss, primarily owing to corneal scarring. Older age, immunosuppression, and uveitis are associated with severe permanent loss of vision secondary to HZO.

Acute Glaucoma Filtering Surgery Failure following Herpes Zoster Ophthalmicus Infection

Herein, we report a case of acute failure of a previously successful trabeculectomy, following an infection with herpes zoster ophthalmicus (HZO). HZO remains a common infection, especially among elderly and immunocompromised patients. There is a strong link between HZO infection, the incidence of secondary glaucoma, and the need for glaucoma filtering surgery. Though, to our knowledge, there are no cases reporting on the effect that a concomitant infection may have on a previously successful trabeculectomy. In our case, a 76-year-old immunocompetent male with primary open-angle glaucoma in both eyes and a history of a successful right eye trabeculectomy 1 year earlier presented with acute primary HZO involving the ophthalmic branch of the right trigeminal nerve. Appropriate topical and systemic treatment was immediately initiated. Three days later, the trabeculectomy bleb showed hyperemia and flattening and concomitant rise of intraocular pressure was noted. A week later, the cutaneous signs were improving yet the trabeculectomy had failed and high intraocular pressure was established, requiring both topical and systemic antiglaucoma medications. Our study suggests that a previously successful trabeculectomy may manifest signs of compromise and subsequent failure following a HZO infection.

Effectiveness of the Recombinant Zoster Vaccine for Herpes Zoster Ophthalmicus in the United States

PURPOSE

To examine the effectiveness of the recombinant zoster vaccine (RZV) for preventing herpes zoster ophthalmicus (HZO) in the general United States population.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Individuals enrolled in the OptumLabs Data Warehouse (OLDW; OptumLabs, Cambridge, MA) who were age eligible for herpes zoster (HZ) vaccination (≥50 years of age) from 2018 through 2019. The OLDW is a longitudinal, de-identified administrative claims and electronic health record database of patients in the United States with commercial insurance, Medicare Part D, or Medicare Advantage METHODS: Patients were required to have 365 days or more of continuous enrollment to be eligible. Those with a diagnosis code of HZ or an immunocompromising condition within 1 year before study inclusion were excluded. Vaccination with the RZV was ascertained by Current Procedural Terminology codes, and HZO was ascertained by International Classification of Diseases, Tenth Revision, codes. Cox proportional hazards regression models were used to estimate the hazard ratio of HZO associated with RZV, and inverse-probability weighting was used to control for confounding. Vaccine effectiveness was calculated from hazard ratios.

MAIN OUTCOME MEASURES

Incidence of HZO in vaccinated versus unvaccinated person-times and vaccine effectiveness were assessed.

RESULTS

From January 1, 2018, through December 31, 2019, a total of 4 842 579 individuals were included in this study. One hundred seventy-seven thousand two hundred eighty-nine (3.7%) received 2 valid doses of RZV. The incidence rate of HZO was 25.5 cases (95% confidence interval [CI], 17.4-35.8 cases) per 100 000 person-years in the vaccinated group compared with 76.7 cases (95% CI, 74.7-78.7 cases) in the unvaccinated group. The overall adjusted effectiveness of RZV against HZO was 89.1% (95% CI, 82.9%-93.0%).

CONCLUSIONS

The effectiveness of RZV against HZO in individuals 50 years of age and older is high in a clinical setting. However, the low vaccination rate in this study highlights the public health need to increase HZV use. Ophthalmologists can play an important role in recommending vaccination to eligible patients.

Stromal Keratitis After Varicella in Children

PURPOSE

We describe here a case series of patients with stromal keratitis of chronic course, a potential manifestation after chickenpox in children.

METHODS

This is a retrospective review of 8 eyes (7 children) with stromal keratitis after varicella seen in our referral cornea center. All patients received a systemic antiviral treatment with oral acyclovir and topical steroid eye drops. Topical cyclosporine eye drops were associated with steroids in case of steroid dependence or steroid-related side effects. Both antiinflammatory treatments were slowly tapered over time.

RESULTS

Median age at diagnosis was 3 years and 4 months. Stromal keratitis was unilateral in 6 children (85.7%) and consisted of superficial nummular keratitis in 4 cases and deep stromal diffuse keratitis in 3 cases. During the median follow-up of 31 months (range, 13-59 months), 6 children had 1 to 6 episodes of relapse. The median duration of topical steroid eye drop was 26 months (range, 2-59 months). Topical cyclosporine eye drops were used with steroids in 3 patients (42.9%). Three patients stopped topical steroids after 2, 5, and 8 months, without recurrence. Four patients were still undergoing treatment after a median of 43 months (range, 26-59 months). All patients regained a best-corrected visual acuity of 20/20 at the end of the follow-up.

CONCLUSIONS

Stromal keratitis after varicella is an entity with a potential chronic course lasting 3 months or more. Steroid dependence and relapses during tapering are 2 major challenges for the management.

The Use of Systemic Steroids in the Treatment of Herpes Zoster Ophthalmicus-Related Ophthalmoplegia: Case Report and Case Meta-analysis

PURPOSE

The role of systemic steroids in the treatment of ophthalmoplegia in the setting of herpes zoster ophthalmicus (HZO) is controversial. We conducted a case report-based meta-analysis to investigate the role of systemic steroid in the recovery of efferent dysfunctions in HZO.

DESIGN

Case-report based meta-analysis.

METHOD

We report a case of herpes zoster ophthalmicus-related ophthalmoplegia (HZORO) in which systemic steroid led to complete resolution of external ophthalmoplegia. We further identified subjects from published cases of HZO-related ophthalmoplegia by searching PubMed and Google Scholar, which elicited 42 articles (49 cases) after excluding those younger than 18 years or with incomplete follow-up data. With the present case, a total of 50 cases are included in the analysis. Main outcome measure is the recovery of efferent dysfunction at the last known follow-up, coded as 1 for complete recovery or 0 for noncomplete recovery. We performed multivariable linear regression and Cox proportional hazards analysis to determine the contribution of steroid duration on the status of complete recovery.

RESULTS

Multivariable linear regression showed significant association between duration of steroid treatment and status of complete recovery (P < .001). Cox proportional hazards analysis showed a hazard ratio of 1.1 (P = .04), indicating that longer treatment duration increased chance of complete recovery. Age, gender, and initial steroid dose did not contribute significantly to recovery status.

CONCLUSION

Our meta-analysis suggests that extended steroid taper may aid the recovery of ophthalmoplegia in the setting of HZO and should be investigated further in the future.

Epidemiology of Viral Induced Anterior Uveitis

Purpose: Viral agents are the most common cause of infectious anterior uveitis worldwide. The purpose of this review is to analyze the frequency, gender and racial differences of viral anterior uveitis (VAU) in various populations.Methods: Systematized literature review of epidemiological reports of VAU cited in PubMed, EMBASE and the Cochrane Library database published until June 30th, 2020.Results: A total of 12 clinical studies on epidemiology of definite VAU and 36 clinical studies of presumed VAU were identified. Members of Herpesviridae family represent the most common causes of VAU. Other less frequently reported causes, such as rubella and endemic viruses (HTLV-1, Chikungunya, Dengue, Ebola, Zika virus) were also analyzed.Conclusion: HSV, VZV are prevalent worldwide. CMV is more frequent in Asia, and rubella in the West. However, due to globalization and air travel, HTLV-1, Chikungunya, Dengue and Ebola may become important causes of VAU across the world.

Text-Based Identification of Herpes Zoster Ophthalmicus With Ocular Involvement in the Electronic Health Record: A Population-Based Study

Background

Diagnosis codes are inadequate for accurately identifying herpes zoster ophthalmicus (HZO). Manual review of medical records is expensive and time-consuming, resulting in a lack of population-based data on HZO.

Methods

We conducted a retrospective cohort study, including 87 673 patients aged ≥50 years who had a new HZ diagnosis and associated antiviral prescription between 2010 and 2018. We developed and validated an automated natural language processing (NLP) algorithm to identify HZO with ocular involvement (ocular HZO). We compared the characteristics of NLP-identified ocular HZO, nonocular HZO, and non-HZO cases among HZ patients and identified the factors associated with ocular HZO among HZ patients.

Results

The NLP algorithm achieved 94.9% sensitivity and 94.2% specificity in identifying ocular HZO cases. Among 87 673 incident HZ cases, the proportion identified as ocular HZO was 9.0% (n = 7853) by NLP and 2.3% (n = 1988) by International Classification of Diseases codes. In adjusted analyses, older age and male sex were associated with an increased risk of ocular HZO; Hispanic and black race/ethnicity each were associated with a lower risk of ocular HZO compared with non-Hispanic white.

Conclusions

The NLP algorithm achieved high accuracy and can be used in large population-based studies to identify ocular HZO, avoiding labor-intensive chart review. Age, sex, and race were strongly associated with ocular HZO among HZ patients. We should consider these risk factors when planning for zoster vaccination.

Enrollment in the Zoster Eye Disease Study

PURPOSE

To present the results of a survey of the Zoster Eye Disease Study (ZEDS) investigators regarding barriers to the enrollment of study participants and approaches to overcome them.

METHODS

ZEDS is a multicenter randomized clinical trial supported by the National Eye Institute to determine whether prolonged suppressive valacyclovir reduces the complications of herpes zoster ophthalmicus (HZO), relative to placebo. Enrollment of study participants is currently far below expectations. An institutional review board-approved anonymous internet survey was conducted of ZEDS investigators to study their experiences and opinions regarding barriers to enrollment and various approaches to overcome them.

RESULTS

The overall survey response rate was 54% (79/145). Only 29% (23/79) agreed that it is easy to enroll study participants. Regarding patient barriers, 69% (55/79) agreed that HZO patients want to be treated with antiviral medication and 69% (54/78) agreed that HZO patients on antivirals do not want to be randomized. Regarding personal barriers facing investigators, 91% (72/79) agreed that antivirals are effective and 100% that the research questions ZEDS is designed to answer are very important. Fewer than 30% of respondents believed that steps taken to increase enrollment have been very helpful. Over half (54%, 42/78) believed that advertising on social media would be moderately or very effective.

CONCLUSIONS

Belief among ZEDS investigators that antivirals are effective, and the preference of patients to be treated with antivirals rather than be randomized in ZEDS, are major barriers to enrollment. New approaches to overcoming barriers are necessary to develop an evidence-based standard of care for treatment of HZO.

Corneal Refractive Surgery in Patients with a History of Herpes Simplex Keratitis: A Narrative Review

The incidence of herpes simplex keratitis (HSK) in patients following corneal refractive surgery is higher than in the general population, and several case reports of ocular morbidity in HSK infection following corneal refractive surgery have been published. HSK is listed by the American Academy of Ophthalmology as a relative contraindication to corneal refractive surgery, although specifics have not been further elucidated. This review summarizes the current literature regarding reactivation of HSK following corneal refractive surgery and provides a guideline for considering corneal refractive surgery in a patient with a previous history of HSK. Based on the current literature, we recommend that corneal refractive surgery is appropriate for patients with a history of HSK without multiple recurrences who have had no evidence of disease for at least one year. In addition to a thorough history and physical examination, we also recommend these patients begin 400 mg twice daily of oral acyclovir or valacyclovir 500 mg once daily for two weeks prior to surgery and continue this regimen for at least two weeks postoperatively or while on topical steroids.

[Ocular manifestations of viral diseases]

Les infections virales peuvent toucher l’ensemble des tuniques oculaires et mettre en jeu la fonction visuelle à plus ou moins courte terme. Les kératites et kérato-uvéites liées au virus HSV-1 sont les atteintes les plus fréquentes. Les récurrences entraînent une opacification cornéenne irréversible qui en fait la première cause de cécité d’origine infectieuse dans les pays occidentaux, et justifient un traitement antiviral préventif au long cours. Le zona ophtalmique (10 à 20 % des zonas), peut s’accompagner d’atteintes oculaires sévères (kératites, kérato-uvéites), dont 30 % deviennent chroniques/récurrentes, et de douleurs post-zostériennes, redoutables dans le territoire trigéminé. Les rétinites nécrosantes liées aux herpesvirus (HSV, VZV, CMV), sont rares mais constituent des urgences fonctionnelles absolues nécessitant un traitement antiviral par voie intraveineuse et intravitréenne. Les conjonctivites à adénovirus constituent la première cause de conjonctivite infectieuse. Le plus souvent bénignes, elles sont extrêmement contagieuses et peuvent se compliquer de lésions cornéennes invalidantes persistant plusieurs mois, voire années. Certaines arboviroses s’accompagnent de manifestations oculaires inflammatoires. Dans le cas du Zika, les infections congénitales peuvent se compliquer d’atrophie maculaire et/ou optique. Les conjonctivites sont très fréquentes à la phase aiguë de la maladie à virus Ebola, dont 15 % des survivants présentent des atteintes inflammatoires chroniques sévères liées à la persistance du virus dans les tissus uvéaux. Enfin, dans le cadre de la COVID-19, les conjonctivites ne sont pas très fréquentes mais peuvent être inaugurales, voire au premier plan et sont associées à une excrétion virale lacrymale qui doit faire prendre toutes les précautions.

Successful oral treatment of third cranial nerve palsy and optic neuritis from neglected herpes zoster in an immunocompetent patient

Purpose

Herpes zoster (HZ) is an acute viral eruption caused by the reactivation of varicella zoster virus (VZV), a herpes virus causing chicken pox in children. We aimed to report a 3-month neglected case of acute herpes zoster-induced third nerve palsy and optic neuritis, followed by a late-onset keratouveitis in an immunocompetent young adult.

Observations

A 36-year old immunocompetent Egyptian male patient presented with 3-month complaints of blurred vision and drooping of his left upper eyelid that appeared 4 days after a herpetic rash. He had been diagnosed with herpes zoster ophthalmicus (HZO) of the left eye. However, he had not received any systemic antiviral treatment. The patient had an abnormal head posture with post-eruptive scars on the left forehead and the nose tip. Examination revealed weakness of elevation and adduction, partial ptosis, and mid-dilated non-reactive pupil in the left eye. A relative afferent pupillary defect (RAPD) was present in the affected eye. His blood sugar and blood pressure were within normal limits. Contrast magnetic resonance imaging (MRI) showed no space-occupying lesion. However, there were enhancement and enlargement of the left optic nerve on T1-weighted images, denoting optic neuritis. A diagnosis of acute left third nerve palsy with pupil involvement and optic neuritis secondary to HZO was made. Despite late treatment with oral acyclovir and prednisolone, the patient recovered. One and a half months later, he developed a late-onset keratouveitis about 8 months after the rash onset. After the resolution of the episode, oral acyclovir was continued at a prophylactic dose (400 mg BID).

Conclusions and importance

HZ is a rare cause of third nerve palsy with pupil involvement and optic neuritis. Oral acyclovir and steroids were effective in the delayed treatment in this case. Abnormal optic nerve enhancement on MRI 3 months after the appearance of vesicular rash may suggest chronic HZ activity. Concurrent optic neuritis and third cranial nerve palsy in the absence of other signs of orbital apex syndrome can be seen in cases of HZO. Regular follow-up of patients with HZ is important for detecting recurrence and initiating prompt treatment.

Clinical Efficacy of Short-Term Peripheral Nerve Stimulation in Management of Facial Pain Associated With Herpes Zoster Ophthalmicus

Objective

Peripheral nerve stimulation may be an alternative option to treat severe facial pain. We assessed the application of peripheral nerve stimulation for pain management in patients with herpes zoster ophthalmicus.

Method

A retrospective analysis was conducted in patients suffering severe facial pain caused by ophthalmic herpetic lesions. We identified the change in pain severity before and after peripheral nerve stimulation for up to 12 months.

Results

Eighteen patients were enrolled. Their mean age was 70.8 ± 9.5 years. Fifteen patients presented with subacute pain for 1–3 months, and three patients suffered postherpetic neuralgia. Dramatic relief from pain was achieved in 83% of patients (15 out of 18) upon initial removal of the stimulator, with pain reduction of > 50%. The long-term analgesic effect was reported at the 6- and 12-month follow-ups, with reductions in the visual analog scale of 4.8 ± 1.2 (n = 18) and 5.4 ± 1.4 (n = 11), respectively. The prevalence of postherpetic neuralgia was 7% (1 out of 15) in the subacute pain group. No obvious adverse effect was observed.

Conclusion

Peripheral nerve stimulation may be an efficacious and safe approach for pain control in patients with herpes zoster ophthalmicus.

Herpes Zoster Ophthalmicus and Limbal Ischemia in A Patient with History of Ocular Graft-Versus-Host Disease

Purpose:

To report a rare complication of herpes zoster ophthalmicus (HZO).

Methods:

A 27-year-old man with a history of graft-versus-host disease (GVHD) presented with pain and redness in his left eye along with vesicular eruptions on the same side of the forehead from 40 days earlier.

Results:

In this case report, we present a case of HZO with severe limbal ischemia in a patient with ocular GVHD. The patient was administered with intensive topical preservative-free lubrication, topical preservative-free antibiotics, topical autologous serum 20%, topical non-preservative steroid (methylprednisolone 1%), and oral valacyclovir 1 g twice daily. The patient underwent amniotic membrane patch surgery on bulbar conjunctiva and cornea, lateral tarsorrhaphy, and punctal occlusion for the left eye.

Conclusion:

In this report, severe and extensive limbal ischemia caused by herpes zoster virus in an immunocompromised patient is reported.