Sex: M
Vaccine: VARZOS
Symptoms: Rash, Slit-lamp tests abnormal, Varicella zoster virus infection, Visual acuity reduced, Visual impairment
Clinical narrative: Information has been received from the authors in a published literature article title as stated below and refers to a 63-year-old healthy man who presented with a change in vision of the left eye after blunt trauma. At the time of presentation, the primary care physician diagnosed the patient with a corneal abrasion and started on a topical antibiotic. The patient was also told to follow-up with an ophthalmologist. After a detailed history at the time of his eye examination, the patient disclosed that 3 months before presentation (on an unspecified date), he had received the shingles vaccine ZOSTAVAX (dose, frequency, route, anatomical location, lot number and expiration date were not reported), and 2 months later developed a varicella skin eruption on the right side of his face with an insidious deterioration in vision. Immediately after the skin eruption, the patient was treated with a short course of acyclovir 800 mg with eventual resolution. Ocular examination (unknow date) showed the best-corrected visual acuity to be 20/20 in the right eye and 20/150 in the left eye. lntraocular pressure was 13 mmHg in the right eye and 12 mmHg in the left eye. On external examination, both eyes appeared quiet without evidence of ciliary or conjunctival injection. Slit-lamp examination in the right eye showed normal depth and content of the anterior chamber (AC), 2+ nuclear sclerotic changes of the lens, and no cells or haze in the anterior vitreous. Dilated fundus examinations in the right eye showed a C/D ratio of 0.2, normal foveal reflex, and normal blood vessels. However, slit-lamp examination in the left eye demonstrated 4+ cell and 2+ flare in the AC and 2+ cell and 2+ haze, mainly central, in the anterior vitreous. Dilated fundus examinations in the left eye revealed a C/D ratio of 0.3, a grossly flat macula, and multiple whitish satellite retinal lesions diffused in the inferior and superior nasal retinal quadrants. There were no apparent snowballs or snow banks. The diagnosis of acute retinal necrosis (ARN) in the left eye was made. Varicella-zoster virus infection of the left eye was confirmed with an Anterior chamber (AC) paracentesis and polymerase chain reaction. The patient was treated with 2 consecutive intravitreal injections of foscarnet over 2 days and was also started on a therapeutic dose of valganciclovir and subsequently switched to VALTREX 2 gm four times a day. The patient was evaluated 3 days after starting VALTREX, and on examination, the vitritis showed mild improvement. After 7 days of treatment, the patient was seen by a uveitis specialist and was started on a 6-day tapering course of 0.75 mg-kg-1-day-1 oral prednisone. On follow-up, the AC reaction had lessened; however, the vitritis persisted. The dose of oral prednisone was increased to 1 mg/kg-1-day-1 oral (PO), followed by a tapering schedule. A topical regimen composed of prednisone and mydriatic eye drops, in addition to VALTREX 2 gm four times a day, was continued while monitoring kidney function. The authors reported that this case showed how varicella-zoster virus (VZV) reactivation after shingles vaccination may predispose both immuno­competent and immunocompromised individuals, to herpes-zoster ophthalmicus leading to ARN of one eye with contralateral varicella skin eruption. Eliciting a detailed history, performing AC paracentesis, and obtaining a skin biopsy can be crucial in providing prompt and appropriate treatment. Although VZV reactivation is rare, clinicians should always consider the risks associated with administering the shingles vaccine and counsel patients appropriately. Upon internal review the event acute retinal necrosis was considered to be medically significant