PREVENTING ZOSTER

Ophthalmologists can help prevent herpes zoster ophthalmicus (HZO) by strongly recommending the herpes zoster vaccine (Zostavax, Merck) to patients aged 50 and over, Elisabeth J Cohen MD told Cornea 2013 at the American Academy of Ophthalmology meeting in New Orleans.

Now professor of ophthalmology at New York University School of Medicine, New York City, Dr Cohen cared for many HZO patients during 30 years at Wills Eye Hospital in Philadelphia, where she headed the cornea service. Then she contracted HZO herself. “I got herpes zoster ophthalmicus in my 50s and despite the very best care, I lost vision and had to give up practising ophthalmology. Personally, I strongly recommend this vaccine for people in their 50s,” she said.

Herpes zoster is caused by reactivation of the varicella-zoster virus, which also causes chicken pox and is latent in almost all adults. While zoster cannot technically be an epidemic because it is not communicable, its scope may qualify, Dr Cohen said.

With mean age of onset in the US at 52 years, 30 per cent of persons will have zoster in their lifetime, rising to half at age 85, Dr Cohen noted. Incidence is higher among women.

Recent studies

Based on 21 recent national studies, overall European incidence is about 3.4 per 1,000 person-years. That means about 1.7 million new zoster cases in Europe annually (Pinchinat et al. BMC Infect Dis 2013; 13:170).

Beyond the painful rash and potentially permanent ocular damage in its chronic phase, zoster presents other long-term risks, Dr Cohen said. One-third of patients over 80 suffer post-herpetic neuralgia. HZO raises stroke risk within one year 4.5 times (Lin. Neurology 2010; 74:792). Studies in Taiwan found a nine times risk increase for cancer (Ho Ophthalmology 2011; 118:1076-81), and 1.68 times risk for lymphoid malignancies (Liu BMC Cancer 2012; 12:503).

Available in the US since 2006, the zoster vaccine launched in Europe last year. The vaccine reduces incidence 51 per cent in people aged 60+ (Oxman NEJM 2005; 352:2271) and 68 per cent in people aged 50 to 59 (Schmader Clin Infect Dis 2012; 54(7):922-28). The vaccine also reduces severity, duration and postherpetic neuralgia. Nonetheless, in 2012, 20 per cent of eligible persons aged 60 and older in the US had received the vaccine (MMWR 2014 Feb 1; 62:66-72).

In a study Dr Cohen conducted, many patients followed the recommendation of the ophthalmologist to have the vaccine, but the recommendation of the primary care doctor is very important. (Jung JJ, Elkin ZP, Li X, Goldberg JD, Edell AR, Cohen MN, Chen KC, Perskin MH, Park L, Cohen EJ. Increasing use of the vaccine against zoster through recommendation and administration by ophthalmologists at a city hospital. Am J Ophthalmol. 2013; 155:787-95.)

Antiviral drugs including valacyclovir are also effective in treating acute HZO.

Elisabeth Cohen: Elisabeth.cohen@nyumc.org