Sex: M
Vaccine: VARZOS
Symptoms: Keratitis, Ophthalmological examination abnormal, Uveitis, Vision blurred
Clinical narrative: Uveitis reactivation; Headache; blurred vision in the right eye; foci of anterior stromal keratitis; stellate keratic precipitates; anterior chamber cell; This case was reported in a literature article and described the occurrence of uveitis in a 69-year-old male patient who received Herpes zoster (Shingrix) for prophylaxis.  The patient's past medical history included idiopathic (ipah) and uveitis (mild intermediate).   On an unknown date, the patient received the 2nd dose of Shingrix. On an unknown date, 1 month after receiving Shingrix, the patient experienced uveitis (serious criteria GSK medically significant and other: serious as per reporter), headache (serious criteria other: serious as per reporter), blurred vision (serious criteria other: serious as per reporter), keratitis (serious criteria other: serious as per reporter), keratic precipitates (serious criteria GSK medically significant and other: serious as per reporter) and anterior chamber cell (serious criteria other: serious as per reporter). The patient was treated with valaciclovir hydrochloride (Valacyclovir) and prednisolone acetate. On an unknown date, the outcome of the uveitis, blurred vision, keratic precipitates and anterior chamber cell were recovering/resolving and the outcome of the headache was unknown and the outcome of the keratitis was recovered/resolved.   The reporter considered the uveitis, headache, blurred vision, keratitis, keratic precipitates and anterior chamber cell to be related to Shingrix.  Additional details were reported as follows: This case was reported in a literature article and described the occurrence of uveitis reactivation in a 69-years-old male patient, who was vaccinated with Shingrix (GlaxoSmithKline) for prophylaxis. This case corresponds to a case reported in this literature article. The patient had a history of idiopathic recurrent bilateral anterior and mild intermediate uveitis. No information on patient's family history, concurrent condition or concomitant medication was provided. On an unspecified date, the patient received 2nd dose of Shingrix (administration route and site unspecified; batch number not provided). The age of vaccination was not provided but it could be 68 years or 69 years. On an unspecified date, 1 month after the 2nd dose of vaccination, the patient presented with sudden onset headache and blurred vision in the right eye. The patient had finished a course of topical prednisolone acetate 1% 3 months ago right eye (OD) and 2 months ago left eye (OS), and his uveitis was quiescent on examination two months prior. On exam, the patient's best corrected vision was 20/50 OD and 20/30 in the unaffected OS. Intraocular pressures were within normal limits in both eyes. On exam, it was noted several foci of anterior stromal keratitis, stellate keratic precipitates and trace anterior chamber cell OD; examination OS was unremarkable. On Pentacam optical densitometry of the cornea, there was loss of clarity in the regions of stromal keratitis. The patient was started on valacyclovir 1000 mg three times daily. Three days later the anterior stromal keratitis resolved and there was improvement of anterior chamber cell to 0.5+. Prednisolone acetate 1% drops two times daily OD was initiated for two weeks and the patient completed a two-week course of valacyclovir 1000 mg three times daily followed by 500 mg daily as prophylaxis. At follow up 1 month after initial presentation his vision improved to 20/30 OD, the stromal keratitis remained resolved, the number of keratic precipitates was reduced and anterior chamber inflammation was quiescent. Corneal densitometry demonstrated improvement. [Pentacam corneal densitometry display of the right eye compared corneal light backscatter during active keratitis and following resolution of the keratitis. The backscatter values were higher in the central (0-2 mm) and second (2-6 mm) annular zones during active keratitis. The peak in maximal corneal densitometry at the 4 mm annulus during active keratitis showed relative flattening after keratitis resolution (Arrows, Heat Map), consistent with the clinical improvement in corneal clarity]. The authors commented, "The RZV is an adjuvanted subunit vaccine for immunization against herpes zoster. RZV contains recombinant VZV glycoprotein E and the adjuvant AS01B, which is composed of two immunostimulants: a toll-like receptor 4 agonist (3-O-desacyl-40-monophosphoryl lipid) and a saponin derived molecule QS21 (from the tree Quillaja saponaria). The adjuvant induces an innate immune-cell mediated response, which enhances glycoprotein E antigen presentation to T cells and induces increased production of antibodies and CD4+ T cells specific to the VZV glycoprotein E. Here, we present a spectrum of cases with uveitis activation in patients with previously controlled ocular inflammation following vaccination with the RZV. Viral DNA from previous zoster infection has been detected in corneal tissue up to eight years following the initial clinical presentation with herpes zoster ophthalmicus. One possible mechanism for post-RZV ocular inflammation is that the cell-mediated response to RZV vaccination reacts with this residual viral DNA which results in reactivation of viral keratitis or potentially keratouveitis. We propose this as the possible cause for recurrent inflammation in our third case. The mechanism for reactivation of uveitis in our other two cases is less clear. We hypothesize that in case 1, the patient with longstanding multifocal choroiditis who was controlled on immunosuppression, the upregulation of humoral and cell-mediated responses following vaccination may have resulted in reactivation of immune cells directed against uveal antigens in addition to the desired response against the VZV glycoprotein. The uveitis reactivation in case 2 is consistent with a viral process, particularly given the keratitis. The underlying etiology may be a failure of vaccination since the patient's prior uveitis presentation, which was a bilateral process without keratitis that was well controlled with short courses of topical corticosteroids, was not consistent with a viral etiology. Despite the possibility of uveitis reactivation following RZV, RZV vaccination is an important component of preventative health. The presented cases should not deter patients and physicians from recommending the RZV vaccine; RZV is efficacious in preventing herpes zoster and postherpetic neuralgia. Rather, this report highlights the importance of ensuring primary care providers are aware of a patient's history of immune-mediated eye disease. We recommend that patients with a history of uveitis discuss plans for RZV vaccination with their ophthalmologist and primary care provider in advance, so appropriate post-vaccination ocular monitoring occurs." The authors concluded, "Uveitis recurrence is an infrequent but serious potential ocular side effect of recombinant zoster vaccination. Reactivation of uveitis is an uncommon complication of RZV vaccination." This is 1 of the 3 valid cases reported in the same literature article.; Sender's Comments:  US-GLAXOSMITHKLINE-US2021GSK140934:Same reporter