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Herpes Zoster Vaccine Can Save Your Patients’ Eyesight

The first vaccine for shingles in the United States — Zostavax — was approved by the US Food and Drug Administration in 2006. The landmark study, published in the The New England Journal of Medicine in 2005, involved over 38,000 adults aged 60 years or older and found that the vaccine reduced the incidence of herpes zoster by 51%.[1] Because the FDA study only included individuals who were 60 years or older, it was only approved for that group. Plus, this vaccine was a live attenuated virus, so it was contraindicated in most immunocompromised individuals. In 2011, FDA approval was expanded to include persons aged 50 years or older.

A 50% reduction, admittedly, is not great, but as a corneal specialist and having seen firsthand the devastation that herpes zoster can do to the eye (this is called herpes zoster ophthalmicus [HZO]), I got this vaccine as soon as I was eligible and encouraged all of my relatives, friends, and patients who were eligible to do the same.

In 2017, a recombinant subunit herpes zoster vaccine (Shingrix) was FDA approved. The clinical trial leading to that FDA approval involved more than 15,000 participants aged 50 years or older, and the vaccine’s effectiveness proved to be over 96% in all age groups.[2] Obviously, 96% is a lot better than 51%, plus this vaccine is not a live attenuated virus and therefore could be used in immunocompromised individuals. Because it had been many years since I received my original shingles vaccine, I got this new vaccine as soon as I could from my doctor’s office (there were availability issues for the first year or two after FDA approval) and again encouraged all of my relatives, friends, and patients who were eligible to do the same.

We all know that results in clinical trials are not always duplicated in the real world, and we also know that these trials looked at herpes zoster in general and not HZO. So, does this new shingles vaccine really prevent HZO?

Lu and colleagues used a large insurance database that included over 4.8 million individuals over the 2-year period from 2018 to 2019 to answer this question. They found that the recombinant zoster vaccine is 89% effective against HZO. Pretty damn good in real life! However, they also found that a woefully low 3.7% of eligible patients received two valid doses of the vaccine.[3] That’s not totally surprising because they state that only 31% of adults aged 60 years or older had received the original zoster vaccine almost a decade after FDA approval.

As ophthalmologists, we understand how terrible HZO can be. My former partner in practice at Wills Eye Hospital, Dr Elisabeth Cohen, has stated publicly that one of the reasons she had to stop clinical practice was because of poor vision that resulted from her own case of HZO. She is now at New York University running a large multicenter trial to determine the efficacy of suppressive antiviral treatment for HZO.

What can we as eye care professionals do? We should be asking all of our patients who are 50 years or older whether they have had a shingles vaccine and encourage them all to get one! In my experience, that question is much less politically charged than asking about COVID vaccination. I’m in the process of customizing our EHR system to require the technician to ask every patient who is over 50 years old whether and when they were vaccinated for zoster. I can then easily see who is not vaccinated and encourage them to get the shingles vaccine. We have to do a better job!

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