Herpes Zoster Ophthalmicus in an Immunocompetent Child With Concurrent COVID-19 Infection: A Case Report and Literature Review.

Herpes zoster ophthalmicus (HZO) is a rare complication of herpes zoster (HZ) that can occur in pediatric patients. It can have significant implications for affected individuals, with the potential for patients to experience ocular complications. Additionally, HZO can have a chronic disease course, requiring long-term treatment in some patients. Following the progression of the COVID-19 pandemic, reports worldwide have identified a potential association between HZO and COVID-19. This case report describes a rare case of a child presenting HZO during a COVID-19 infection.

Herpes Zoster Ophthalmicus in a Healthy Toddler Fully Immunized Against Varicella-Zoster Virus: A Case Report and Review of Treatment Strategies in Children.

Herpes zoster ophthalmicus (HZO) is a rare presentation of herpes zoster in children; however, it may become chronic and debilitating. The pathophysiology of HZO complications is not completely understood and may include virus virulence, vascular and neural inflammation and immune reactivity. Therefore, clinical experts suggest an antiviral agent combined with topical steroids, but treatment duration and the need for secondary prophylaxis, given the likelihood of recurrence, are not clearly defined. We present a complex case of HZO in a varicella zoster virus (VZV)-vaccinated toddler successfully treated with acyclovir and topical steroids. We also present a review of the relevant literature regarding the therapeutic management and long-term sequelae of HZO in children.

Herpes zoster ophthalmicus after COVID-19 vaccine booster in healthy younger adult: a case report.

There were growing reports of herpes zoster reactivation after the coronavirus disease 2019 (COVID-19) vaccination, including a more severe form, herpes zoster ophthalmicus (HZO). A 35-year-old male presented HZO in his left V1 dermatome 10 days after his COVID-19 vaccine booster with Moderna (messenger RNA-1273). He had no history of chronic disease, immunocompromised, autoimmune, malignancy, or long-term immunosuppressive drug use. The rash improved without any further complications after being treated with oral valacyclovir for 7 days. This was a unique case of HZO after the COVID-19 vaccine in a booster setting in healthy younger adults. The association of herpes zoster after a COVID vaccine remained inconclusive and potentially coincidental, especially without the known risk factor. However, we would like to add a report to increase awareness among physicians and the general population, for early recognition and treatment with an antiviral.

Incidence of Ocular Herpetic pathologies in a hospital setting, United Kingdom

Purpose : The incidence of ocular herpetic pathologies, in particular Herpes Zoster Ophthalmicus (HZO), has seemingly been on a rise over the past years, especially among the elderly and immunocompromised. The nature of this rise is likely multifactorial ranging from access to Shingles vaccination programmes, potential increase in immunocompromised individuals, social factors and most recently, Covid-19 infection. The relationship between Covid-19 and ocular herpetic pathologies has anecdotal basis. Certain studies have hypothesized T-cell dysfunction as a mechanism of Varicella Zoster virus reactivation in patients affected by Covid-19. This retrospective, observational study analyses the pattern of incidence of ocular herpetic pathologies in a secondary care centre, United Kingdom (UK). Methods : This study was set in an eye casualty clinic in Queens Hospital, Burton-on-Trent (University Hospitals Derby & Burton NHS, UK). Diagnoses of each patient was recorded in the Eye Casualty Patient Register. Data was extracted from three time periods-i. Precovid pandemic (July -December 2019), ii. Pandemic (July-December 2021) and iii. Post coronavirus vaccine introduction, UK (April and May 2021). Extracted data was pooled into the following groups-Herpes Simplex Keratits (HSK)/ HZO/ Shingles/Herpetic Kertatouveitis/ Herpes Zoster/Herpes Simplex/Herpes simplex endothelitis. Results : The data between pre-pandemic and post-pandemic periods highlighted an increasing incidence of certain ocular herpetic conditions. Highest number of diagnoses were recorded as HSK and HZO. HSK accounted for the highest incidence across all time periods-41% (pandemic), 34% (pre-pandemic) and 37.5% (after vaccine introduction). On the other hand, similar incidence is noted with HZO diagnoses-32.9% (pandemic), 32.7% (pre-pandemic) and 37.5% (after vaccine introduction). Conclusions : Overall, a gradual increase in incidence of ocular herpetic pathologies was observed from 2019-2021 at this centre. Multiple factors could be responsible for this rise, with Covid-19 infection as a potential factor. However, there is insufficient data to draw up a definitive association between the increasing incidence of such conditions and Covid-19, especially as the immune response to the infection and vaccinations are poorly understood. Larger, multi-centre studies would be required to assess the burden of incidence in the UK.

Epidemiology Of Herpes Zoster Ophthalmicus in context of the SARS-CoV2 (COVID) pandemic

Purpose : The incidence of herpes zoster ophthalmicus (HZO) may be increasing, however the impact of the SARS-CoV2 pandemic (COVID) on HZO epidemiology is unclear. This study seeks to determine the variation in the incidence of HZO over the past 6 years with a special focus on its correlation with overall systemic herpes zoster (SHZ) incidence and HZO monthly and seasonal changes before and after the onset of COVID. Methods : This is a hospital-based epidemiology study of patients attending Duke University Hospital System (DUHS) between 01/2016 and 10/2021 via Duke Enterprise Data Unified Content Explorer (DEDUCE) data with corresponding ICD codes for HZO and SHZ diagnosis. The analysis calculated monthly incidence of novel consults of HZO and SHZ with emphasis on demographics, seasonal variation, and the changes in rates with the COVID pandemic (estimated to impact DUHS population starting in 03/2020). Results : 24896 patients presented with SHZ at DUHS in the study period, of whom 2921 (11.7%) suffered from HZO. The mean age at the incident episode of HZO was 62.8±15.6 years. Most patients were white (78%), female (63.5%), above 50 years old (79.5%) and non-smokers (61.5%). Over the study period SHZ experienced an overall decline in its incidence, however HZO incident cases have been slightly increasing with a mean of 37/month in 2016, 47/month in 2019, and 50/month in 2021. The ratio of monthly incidence HZO/SHZ demonstrates a steady increase from an annual 9% in 2016 to 13.4% in 2019 and 15.5% in 2021. Interestingly, HZO annual peak incidence steadily emerged in the months of November and February throughout all the years. Since COVID onset, the mean monthly incidence of SHZ decreased significantly (373.1 +/- 35 vs 312.1 ± 28, p<0.0001). However, the mean monthly incidence of HZO exhibited a statistically significant increase (39.5 ± 10 vs 46.7 ± 16;p=0.025). Likewise, the trendlines of HZO/SHZ exhibited a significant increase since COVID (10.6% ± 4.6 to 15.1% ± 2.7;p<0.0001). Conclusions : These study findings point that HZO incidence may be increasing, despite an overall lower SHZ incidence, which may suggest a distinct mechanism for HZO appearance despite vaccination efforts. A specific seasonal variation with winter peaks was observed, which should guide physicians towards early recognition of HZO. COVID, directly or indirectly, may have accelerated the already increasing HZO incidence.

Risk of herpes zoster ophthalmicus following COVID-19 vaccination in a large US claims database

Purpose : To determine whether there is an increased risk of herpes zoster ophthalmicus (HZO) following COVID-19 vaccination. Methods : Retrospective observational study utilizing OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de- identified administrative claims and electronic health record data. A cohort study design and a self-controlled design were both utilized to investigate HZO following vaccination, defined by an ICD-10 diagnosis code within 30 days after vaccine administration (or up to the second dose if a second dose was administered), plus a new prescription or dose escalation of antivirals within 5 days of HZO diagnosis. Using a cohort design, COVID-19 vaccinated individuals from 12/11/2020- 6/30/2021 were compared to two influenza-vaccinated cohorts: a pre-pandemic group (1/1/2018-12/13/2019) and an early pandemic group (3/1/2020-11/1/2020). Cox proportional hazard models were used to identify unadjusted and adjusted hazard ratios for HZO. Using a self-controlled design, the incidence rate ratio comparing the risk of HZO in the risk intervals following COVID-19 vaccination to a control interval 60 to 90 days prior to the first dose was estimated using conditional Poisson regression. Results : Among 3,567,715 patients in the COVID-19 vaccinated cohort, there were 60 post-vaccine HZO cases. Patients vaccinated against COVID-19 were not at increased risk of HZO compared to pre-pandemic influenza vaccinated patients (N= 5,101,709;HR= 0.84;95% CI: 0.61-1.16;p= 0.29) and early pandemic influenza vaccinated patients (N= 4,060,412;HR= 0.93;95% CI: 0.64-1.34;p= 0.69) after adjustment for demographics, comorbidities, zoster vaccine, and medication use. Additionally, HZO cases post-COVID-19 vaccination were less likely to be prescribed ophthalmic steroids compared to cases following pre-pandemic and early pandemic influenza vaccination (18.3% vs 29.6% vs 41.4%, respectively). In the self-controlled design, patients were not at increased risk of HZO after COVID-19 vaccination compared to their control interval (IRR= 0.74;95% CI: 0.49-1.12;p= 0.15). Conclusions : There is not an increased risk of HZO following COVID-19 vaccination. These results provide reassurance for the safety of the COVID-19 vaccine from an ophthalmic standpoint.

Unboxing herpes zoster ophthalmicus and the recombinant shingles vaccine

Reactivation of the varicella zoster virus as herpes zoster (shingles) typically affects the peripheral nerves, resulting in a painful rash, most often on the torso. However, it can also manifest ophthalmologically, affecting the ophthalmic division of the trigeminal nerve. This manifestation is associated with a particularly high level of morbidity and may result in blindness. A new recombinant shingles herpes zoster vaccine protects patients against this virus and post-infection sequelae, improving medical and psychosocial outcomes. © 2021 Medicine Today Pty Ltd. All rights reserved.

Herpetic Eye Disease Following the SARS-CoV-2 Vaccinations.

PURPOSE: To describe herpetic ocular infections following SARS-CoV-2 vaccinations. METHODS: A retrospective study of herpetic ocular infections after BNT162b2mRNA vaccination and a literature review. RESULTS: A cohort of five patients: three varicella zoster virus (VZV) and two herpes simplex virus (HSV) cases, as well as 19 literature cases: 9 cases of VZV and 10 cases of HSV post BNT162b2mRNA, AZD1222, mRNA-1273, and CoronaVac vaccinations. All cases presented within 28 days post vaccination. Most VZV and HSV cases (15/19) reported in the literature presented post first vaccine dose, while in our cohort 2 VZV cases presented post second dose and both HSV cases and one VZV case post third dose. The most common presentations were HZO with ocular involvement and HSV keratitis. All eyes had complete resolution; however, one had retinal detachment and three corneal scars. CONCLUSION: Herpetic ocular infections may develop shortly after SARS-CoV-2 vaccinations. Overall, the outcome is good.

Unilateral total ophthalmoplegia with proptosis and loss of vision in a patient of herpes zoster ophthalmicus: A rare case report

Herpes zoster Ophthalmicus accounts for a minority of all patients with zoster infections. It leads to varied clinical presentations, but total unilateral ophthalmoplegia has rarely been reported in the literature. We hereby present a 50-year-old male patient presenting with the above combination for aiding the clinical diagnosis by dermatologists and ophthalmologists. Early initiation of treatment leads to a near total recovery of ophthalmoplegia in the majority of treated patients.

A Case Report of Herpes Zoster Ophthalmicus and Meningitis After COVID-19 Vaccination.

There are several reports that herpes zoster characterized by reactivation of varicella zoster virus (VZV) following coronavirus disease 2019 (COVID-19) vaccines can occur. Herein, we report VZV meningitis, herpes zoster ophthalmicus (HZO), and late neurotrophic keratitis after receiving a second dose of messenger RNA (mRNA) COVID-19 vaccine. A 74-year-old man developed a vesicular skin rash on the forehead, scalp, nose, and left upper eyelid with a severe headache. Five days earlier, he received a second dose of the BNT162b2 mRNA vaccine on his left arm. Ocular examination revealed conjunctival hyperemia and pseudodendrite in the peripheral cornea. VZV was detected in the cerebrospinal fluid using polymerase chain reaction. The patient was diagnosed with HZO and meningitis. The patient was treated with intravenous acyclovir and topical acyclovir ointment and levofloxacin 1.5% eye drops. One month later, he developed a central epithelial defect with a rolled margin, typical of a neurotrophic ulcer. Treatment with a therapeutic contact lens and a combination of topical recombinant human epithelial growth factor and ofloxacin ointment was initiated. At six months after vaccination, the slit-lamp examination findings were stable with a mild corneal superficial stromal haze.

An Innovative Approach to Examining the Waning of Vaccine Effectiveness Using Automated Healthcare Data

Background. We conducted a large real-world study of the long-term vaccine effectiveness (VE) of the live attenuated zoster vaccine (Zostavax;ZVL). Using an innovative approach with automated observational data we measured VE for incident herpes zoster (HZ) and severe HZ outcomes including post-herpetic neuralgia (PHN), herpes zoster ophthalmicus (HZO), and hospitalized HZ. This approach could be useful in long-term effectiveness studies of other vaccines. Methods. We assessed VE against HZ, PHN, HZO and hospitalized HZ for up to 10+ years after vaccination at Kaiser Permanente Northern California. We identified incident cases using diagnoses, laboratory tests and prescriptions, and validated a sample by chart review. For each outcome, we used a Cox regression model with a calendar timeline to estimate VE in relation to year since vaccination. The model for HZ included 11 time-varying vaccination status indicators to denote -- at each timepoint during follow-up -- either the number of years since ZVL vaccination (30 days to < 1 year, 1 to < 2 years, . . ., and 10+ years) or that the individual is unvaccinated (reference group). Analyses were adjusted for demographics and time-varying measures of immune compromise status, healthcare use and comorbidities. Results. From 2007-2018, 1.5 million people contributed to analyses;507,000 (34%) were vaccinated. During 9 million person-years of follow-up, we observed 75,135 HZ cases, including 4,982 (7%) with PHN, 4,418 (6%) with HZO, and 555 (< 1%) who were hospitalized. VE for HZ was 67% (95% Confidence Interval [CI]: 65-69%) in the first year after vaccination, waned to 50% (CI: 47-52%) in the second year after vaccination, and then waned more gradually to 15% (CI: 5-24%) by 10+ years after vaccination. Initial VE was higher against PHN (83%;CI: 78-87%) and hospitalized HZ (89%;CI: 67-97%) with less waning observed over time (42% by Year 8 for PHN and 53% in Years 5 to < 8 for hospitalized HZ). VE against HZO was 71% in Year 1 and waned to 29% in Years 5 to < 8. Conclusion. Our large population, long follow-up and innovative methods let us estimate VE against HZ, PHN, HZO and hospitalized HZ for 10+ years after vaccination. Our approach could help assess waning and need for boosters for vaccines against other agents including COVID-19.

Meeting the challenges of retention and enrollment of study participants in clinical trials during the COVID-19 pandemic from the study leadership perspective: Experience from the Zoster Eye Disease Study (ZEDS).

PURPOSE: To describe steps taken that enabled a high rate of retention and early resumption of enrollment in the Zoster Eye Disease Study (ZEDS), a randomized controlled trial funded by the National Eye Institute, during the first 13 months (3/1/2020-3/31/2021) of the COVID-19 pandemic. METHODS: A number of responses were implemented in ZEDS when the focus shifted to retention of study participants at the beginning of the pandemic including frequent communication with the participating clinical centers (PCCs) about remote visits, local lab work, shipping study medication, and completion of revised case report forms. Additional payments were provided to the PCCs. Remote activation of PCCs continued. Screening and enrollment visits gradually resumed when allowed. RESULTS: Communication with PCCs increased, and average attendance at monthly coordinator teleconferences went up from 17 to 47. Remote visits peaked in April 2020, accounting for 75% (33/44) of study visits, then declined to less than 10% of study visits beginning August 2020. Overall, 97% (590/609) of study visits were completed. Only 5.5% (9/165) of study participants withdrew consent, and 2.4% (4/165) were lost to follow-up. Enrollment returned to pre-pandemic levels by September 2020. DISCUSSION: Strong communication and unwavering commitment, combined with the technological capability for remote work, visits, and shipment of study medication, were key to the successful retention of study participants and resumption of enrollment. CONCLUSIONS: Rapid responses to challenges to trials caused by the COVID-19 pandemic can enable them to continue successfully and provide insights into the planning of future trials.

Varicella-zoster virus reactivation causing herpes zoster ophthalmicus (HZO) after SARS-CoV-2 vaccination - report of three cases.

PURPOSE: We are reporting 3 patients who presented acute zoster ophthalmicus (HZO), an activation of varicella-zoster virus, after mRNA anti-SARS-CoV-2 vaccination, seen directly or referred to our center. CASES: A 73-year-old woman with history of ocular sarcoidosis presented HZO in the right V1 dermatome 16 days after a single booster dose of vaccination (Pfizer BioNTech). A 69-year-old woman presented HZO in her V1 left dermatome, occurring 10 days after her first dose of Pfizer BioNTech vaccine. A 72-year-old woman with no history of autoimmune pathology, candidate for cataract surgery, presented 13 days after the first dose of a Moderna mRNA vaccine with an eruption in the left V1 dermatome. All patients presented the VZV infection after their first dose of a mRNA type of vaccine. Treatment with Valacyclovir 1000 mg × 3/ day for 7-14 days was efficient in all cases. CONCLUSION: Vaccines have been reported in the past to trigger different types of side effects such as viral or flu-like symptoms. It is only logical to note many different side effects for SARS-CoV-2 vaccines as the population vaccinated is exceeding any other number in history. VZV is one of the more severe side effects that can, however, be treated. It is quite obvious that, as far as mRNA vaccines are concerned, and probably also other anti-SARS-CoV-2 vaccines, that the benefit of vaccination certainly outweighs the possible but very low risk of ocular side effects that can mostly be treated.