Sex: F
Vaccine: VARZOS
Symptoms: Photophobia, Sensory loss, Slit-lamp tests abnormal, Visual acuity reduced
Clinical narrative: Herpes Zoster ophthalmicus; Corneal Stromal inflammation/necrotizing stromal keratitis; neurotrophic ulcer and a metaherpetic ulcer; pain; photophobia; corneal thinning; cornea was diffusely edematous; This case was reported in a literature article and described the occurrence of ophthalmic herpes zoster in a 78-year-old female patient who received Herpes zoster (Shingrix) for prophylaxis.   The patient's past medical history included amblyopia and ophthalmic herpes zoster (left-sided 20 years ago but was unable to provide documentation of her clinical presentation). Previously administered products included Shingrix (1st dose received on an unspecified date). Concurrent medical conditions included corneal decompensation (chronic in the eye secondary to forceps injury at birth).   On an unknown date, the patient received the 2nd dose of Shingrix. On an unknown date, 1 week after receiving Shingrix, the patient experienced ophthalmic herpes zoster (serious criteria GSK medically significant), keratitis, eye ulcer, pain, photophobia, corneal thinning and corneal edema. The patient was treated with valaciclovir hydrochloride (Valacyclovir), moxifloxacin hydrochloride (Moxifloxacin), ciprofloxacin (Ciprofloxacine) and erythromycin. On an unknown date, the outcome of the ophthalmic herpes zoster, keratitis, eye ulcer, pain, photophobia, corneal thinning and corneal edema were Recovered/Resolved.   The reporter considered the ophthalmic herpes zoster, keratitis, eye ulcer, pain, photophobia, corneal thinning and corneal edema to be related to Shingrix.  Additional details were provided as follows: This case was reported in a literature article and described the occurrence of Herpes Zoster ophthalmicus reactivation in a 78-years old female patient, who was vaccinated with Shingrix (GlaxoSmithKline) for prophylaxis.  The patient had a history of amblyopia and chronic corneal decompensation in this eye secondary to forceps injury at birth. The patient also had a history of left-sided Herpes Zoster ophthalmicus (HZO) 20 years ago but was unable to provide documentation of her clinical presentation. No information on patient's family history, concurrent condition or concomitant medication was provided. On an unspecified date, the patient received 2 doses of Shingrix (administration route and site unspecified; batch number not provided). The age of vaccination was not provided. On an unspecified date, a week after second dose of Shingrix, the patient reported pain and photophobia that started 1 month before presentation. The patient was referred for progressive in her left eye. The patient had been prescribed erythromycin ointment and ciprofloxacin drops by her outside ophthalmologist without improvement. Visual acuity was counting fingers at 3 ft in the affected eye, and intraocular pressure was 15 mm Hg. Corneal sensation was markedly reduced relative to the contralateral eye. On slit lamp examination, the patient's cornea had a temporal paracentral epithelial defect 1.5x2.0 mm in size with 40% thinning of the underlying stroma. Stromal inflammation was noted around the area of thinning, suggestive of necrotizing stromal keratitis. The surrounding cornea was diffusely edematous. The anterior chamber was quiet. Dilated fundus examination was normal. The right eye had 20/20 visual acuity and unremarkable examination. Given the timing of events, recurrent HZO keratitis after Shingrix vaccination was considered the most probable diagnosis. Other differential diagnoses included a neurotrophic ulcer and a metaherpetic ulcer. The patient was started on oral valacyclovir 1000 mg 3 times daily, topical erythromycin ointment every 4 hours, and hourly preservative-free artificial tears. Three days later, the epithelial defect and thinning persisted. A bandage contact lens was placed, and the patient was started on topical moxifloxacin drops 4 times a day. At 1 week, the bandage contact lens was replaced with self-retained cryopreserved amniotic membrane ring (Prokera; Bio-Tissue) to promote epithelialization. One week later, the Prokera ring was removed. The thinned area had epithelialized with no evidence of further stromal melt. Two months after presentation, the patient reported no new recurrences, and her examination appeared stable. The author commented, "Although risk of HZO reactivation after Shingrix is likely exceedingly low, clinicians should report such rare AEs to improve understanding of which patients are at greatest risk. Histopathological studies have demonstrated persistence of VZV DNA in the human cornea up to 8 years after clinical onset of HZO, suggesting that the virus can reside in the corneal stroma and precipitate recurrent HZO in some patients. In the case of HZO reactivation after vaccination, an increase in cell-mediated immunity can trigger an immune response to VZV in the stroma, leading to stromal keratitis. The Centers for Disease Control and Prevention has no specific guidelines regarding vaccination in patients with previous HZO. Vaccination among age-eligible patients with previous HZO is encouraged unless the patient is having an active episode or flare-up. Once the infection is resolved, there is no specific wait time until vaccination is considered safe. In contrast, antivirals can be continued after Shingrix because the vaccine contains a glycoprotein and not an attenuated live virus, warranting further investigation for its role in preventing HZ in others locations in these patients. Limitations of this case include lack of microbiological testing, including cultures and PCR, to confirm the diagnosis of HZO. In addition, the clinical manifestation of the initial HZO is unknown due to missing previous records." The author concluded, "HZO reactivation after recombinant zoster vaccination is uncommon but possible. Ophthalmologists should remain aware of potential risks of zoster vaccination and take special precautions in patients with HZO history.