Eyeworld Daily News

EW SHOW DAILY 38 Meeting Reporter Saturday, April 18, 2015 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer T here are 1,000,000 new cases a year in the United States alone—that's 1 in 3 people in the U.S.—and the incidence is increasing for unknown reasons. In her keynote lecture at Friday afternoon's "Infec- tions and Inflammations" session at the World Cornea Congress (WCC) VII, Elisabeth J. Cohen, MD, New York, discussed the management and prevention of this condition, herpes zoster, with particular emphasis on herpes zoster ophthalmicus (HZO). Herpes zoster, commonly known as shingles, is the reactiva- tion of a latent varicella zoster virus (VZV) infection (chicken pox). The rate of disease increases with age, peaking in people in their 50s—the age at which Dr. Cohen herself, she said, acquired HZO. Significantly, the increasing incidence, while of unknown provenance, began before the VZV vaccine was introduced, and is not correlated with vaccination. Clinically, zoster involves unilateral vesicular rashes following a dermatomal distribution that respects the midline. If these appear early, the diagnosis can be made quickly and treatment admin- istered as soon as possible. Unfortunately, when typical lesions don't appear early, treatment may be unable to prevent compli- cations that include chronic eye diseases—such as dendriform and stromal keratitis—and postherpetic neuralgia. There are other less obvious but even more serious complications that not only threaten vision but also quality of life—even, Dr. Cohen said, the patient's very life. For instance, zoster is associated with depression. The pain from pos- therpetic neuralgia in particular is a significant cause of suicide in the elderly population. Zoster, particularly HZO, is also a risk factor for potentially fatal stroke. Stroke in these cases is due to chronic VZV infection of cerebral arteries. Meanwhile, cardiovascular disease—due to chronic VZV infection of cardiac arteries—is a risk for relatively young patients. There is also a correlation between zoster and cancers such as lymphoma. More recently, VZV antigen and DNA have been identified in tempo- ral biopsies of giant cell (temporal) arteritis (GCA), and VZV antigens are now considered a trigger for GCA. Antiviral treatment may thus benefit steroid-treated GCA patients. In general, antiviral treatment of herpes zoster reduces the risk of chronic eye disease from 50% to 30% of cases, but does not reduce the risk of postherpetic neuralgia. Antiviral therapy, Dr. Cohen said, should begin in all patients with herpes zoster as soon as possi- ble. "One can't predict who will get severe complications," she said. Prolonged antiviral treatment, she added, requires further investi- gation but may have a role. Prevention where possible is certainly better than treatment. The zoster vaccine, she said, is safe and effective in reducing the burden of illness, as well as the severity of pos- therpetic neuralgia. By preventing VZV infection, it effectively reduces the incidence of zoster. Dr. Cohen said that since 2006, the CDC has recommended that persons aged 60 and above with competent immune systems— particularly unimpaired cellular immunity—receive the vaccine. Since 2011, the vaccine has also been approved by the U.S. Food and Drug Administration (FDA) for persons aged 50–59 with similar criteria. However, Dr. Cohen believes the vaccine is best administered earlier than recommended. "In my opinion, it is better to get the zoster vaccine in your 50s and 60s, but it is never too late," she said. Nonetheless, the CDC main- tains its recommendation due to inadequate information for cost- benefit analysis—for instance, the duration of the vaccine's effect is unknown. In which case, she said, revaccination after 10 years may be worth investigating. Dr. Cohen reiterated the safety of the vaccine, citing its contraindi- cations, which are no different from those of other vaccines—among others, a history of anaphylactic reaction to the components of the vaccine and prolonged high-dose systemic immunosuppressive ther- apy. The full list of contraindica- tions and other information on the vaccine can be found on the CDC website (www.cdc.gov). Ultimately, Dr. Cohen urged ophthalmologists to strongly recom- mend the vaccine against zoster. EW Editors' note: Dr. Cohen has no finan- cial interests related to her lecture. Ophthalmologists urged to 'strongly recommend' zoster vaccine 'Infection and Inflammation' I n addition to Dr. Cohen's keynote address, "Management and Prevention of Herpes Zoster Ocular Disease," these physicians spoke on the following topics: • Penny A. Asbell, MD, New York, spoke on "Advanced Techniques in Diagnosing Infectious Conjunctivitis and Keratitis." • Vishal Jhanji, MD, Hong Kong, spoke on "Special Considerations in Managing Keratitis in Children." • Francis S. Mah, MD, La Jolla, Calif., spoke on "What's New in the Treatment of Bacterial Keratitis?" • N. Venkatesh Prajna, FRCS, Madurai, India, spoke on "Fungal Keratitis—MUTT Trials and Tribulations." • Elmer Y. Tu, MD, Chicago, spoke on "Management of Acanthamoeba and Other Parasitic Keratitis." • Marc Labetoulle, MD, PhD, Paris, spoke on "Update on Management of Herpes Simplex Virus Keratitis." • Vincent de Luise MD, FACS, New Haven, Conn., spoke on "Management of Episcleritis and Scleritis for the Anterior Segment Specialist." EW Dr. Cohen believes the herpes zoster vaccine is best administered earlier than recommended.

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