Uveitis Exacerbation After Varicella-Zoster Vaccination in an Adult FREE

An 86-year-old white man initially had herpes zoster dermatopathy in the right V1 distribution, which was treated promptly with valacyclovir hydrochloride, 1 g 3 times per day. Several days after onset of the dermatopathy, he had pain, redness, and photophobia in the right eye. On examination of the right eye, centrally grouped keratoprecipitates (KPs) (without corneal stromal or epithelial involvement), 2+ cells, and flare were found. The AU was treated with topical prednisolone acetate, 1%. The patient developed a chronic low-grade AU in the right eye; it was well controlled with topical prednisolone acetate, 1%. He gradually developed mild microcystic corneal edema in the right eye, with specular microscopic imaging failing to reveal either a recognizable endothelial mosaic or guttae. The endothelial count in the contralateral eye was normal despite prior uncomplicated cataract surgery in both eyes. The microcystic edema was attributed to endotheliitis, possibly at the onset of the VZV AU as there were no recurrences of KPs or more than minimal AU. Three years after the initial visit, he was weaned completely off prednisolone acetate, 1%, after several months without any evidence of active AU.

During the following 7 months, the patient was followed up without any treatment and there was no recurrence of AU or worsening corneal edema. Subsequently, the patient received the Zostavax vaccine on his own initiative at a pharmacy. Three weeks after vaccination, the patient had visual acuity of 20/200 OD, decreased from his baseline of 20/40 OD. Examination showed worsened corneal edema, centrally located KPs in a linear distribution, and 1+ cells and flare in the anterior chamber. The presence of corneal edema and KPs not localized in the Arlt triangle, normal intraocular pressure, and mild anterior chamber cells suggest recurrent endotheliitis. No corneal epithelial or inflammatory stromal involvement was observed. The patient was treated with valacyclovir hydrochloride, 1 g 3 times per day for 7 days, and intensive topical prednisolone therapy, resulting in return to his baseline condition.

This is a case of an adult patient initially manifesting HZO AU and endotheliitis and then experiencing a uveitis exacerbation that was significant for worsening corneal edema attributed to AU and endotheliitis and temporally associated with Zostavax administration. Because the patient had not previously experienced an exacerbation with KPs and corneal decompensation as occurred after receiving the vaccine, this temporal association suggests that his exacerbation was due to the vaccine.

A single prior case report describes VZV ocular disease, specifically interstitial keratitis, in an adult patient 35 days after vaccination,² and a few pediatric cases of uveitis after administration of a live attenuated VZV vaccine have also been reported.^3- 5 This case adds to the literature suggesting risk of ocular inflammation recurrence after VZV vaccination. While isolated case reports are insufficient to conclude that AU is a contraindication to VZV vaccination, we advise caution in vaccinating patients with a history of HZO.