Describe three cases of uveitis reactivation following immunization with recombinant zoster vaccine (RZV).
One patient developed reactivation of previously controlled multifocal choroiditis within one week of receiving RZV, requiring treatment with systemic corticosteroids. Two patients with previously controlled anterior uveitis developed new anterior segment inflammation after RZV; both were treated with topical corticosteroids and systemic antiviral therapy.
Conclusion and importance
Uveitis recurrence is an infrequent but serious potential ocular side effect of recombinant zoster vaccination.
Herpes zoster is a viral infection caused by varicella zoster virus (VZV) reactivation. There are two vaccinations available for immunization against herpes zoster: zoster vaccine live (ZVL, Zostavax), a live attenuated vaccine available since 2006, and recombinant zoster vaccine (RZV, Shingrix), a recombinant subunit vaccine available since 2017. The most recent Centers for Disease Control guidelines recommend healthy adults 50 years and older undergo vaccination with RZV, which is administered as a two-dose series with 2–6 months between doses. Post-licensure safety monitoring of RZV by the Vaccine Adverse Event Reporting System found a reporting rate of 0.4/100,000 for inflammatory eye disease, with reported events including herpes zoster keratitis and keratoconjunctivitis, two cases of primary herpes zoster iridocyclitis and one report of pre-existing ophthalmic herpes zoster. The recombinant zoster vaccine contains a novel adjuvant, AS01 B , which stimulates a potent immunogenic response that may be responsible for long-lasting cell-mediated immunity. The increased immunogenicity of the adjuvanted vaccine is one advantage of RZV over ZVL, but it raises the potential for immune-mediated events, particularly in those with known inflammatory disease. Here we present three cases of patients with reactivation of their previously controlled uveitis after receiving RZV vaccination.
A 57-year-old Caucasian woman with a history of bilateral multifocal choroiditis controlled on methotrexate 10 mg po weekly presented with an acute decrease in vision in the right eye (OD) and new metamorphopsia in the left eye (OS) five days after receiving her first RZV vaccine. She also reported upper arm swelling at the injection site, chills, malaise, subjective fever, and tinnitus that started 24 hours after the RZV injection. On examination, we measured count fingers vision eccentrically OD (baseline acuity 20/40) and 20/20–2 vision OS with correction. Intraocular pressure was within normal limits in both eyes (OU). Pupils were equal, round, and reactive to light, without evidence of a relative afferent pupillary defect. On slit-lamp exam we noted a quiescent anterior segment OU, an occasional anterior vitreous cell OD, and no vitreous haze in either eye. In the right eye we saw stable posterior segment findings including peripapillary atrophic scarring with temporal thinning of the optic nerve, confluent circular punched-out atrophic macular scars with a small spared foveal region, and vessel attenuation. In the left eye we saw a linear yellow scar temporal to the fovea and a new yellow chorioretinal lesion adjacent to this scar ( Fig. 1 A–D). By fundus autofluorescence we saw stable hypoautofluorescence in the area of prior retinal scars OD and a new area of hyperautoflurorescence at the site of the new lesion OS ( Fig. 1 E–H). Despite the decrease in vision OD, there was no change on macular ocular coherence tomography (OCT) compared to previously identified atrophy and scarring. On macular OCT OS we noted a new outer retinal lesion temporal to prior residual scar ( Fig. 2 A–D). The patient was started on 60 mg of oral prednisone daily and continued methotrexate. On follow-up examination one week later the patient endorsed decreased metamorphopsia in the left eye. Visual acuity was improved to 20/250 OD and remained at 20/20–2 OS. Ocular examination remained stable OD and the new lesion noted at prior examination OS was less elevated ( Fig. 2 E). The patient underwent a prednisone taper over two months without development of recurrent inflammation; however, she developed a secondary choroidal neovascular membrane at the edge of the new scar requiring treatment with intravitreal bevacizumab.