Severity of Herpes Zoster Ophthalmicus: Onset at Younger Than 60 Years Versus 60 Years or Older Neelofar Ghaznawi MD, Ajoy Virdi MD, Amir Dayan, Christopher J. Rapuano MD, Kristin M. Hammersmith MD, Peter R. Laibson MD and Elisabeth J. Cohen MD Authors have no financial interest

Introduction and Purpose  Herpes Zoster Ophthalmicus (HZO) accounts for 15-20% of Herpes Zoster (HZ) in the US and is a significant cause of ocular morbidity. 1  The cornea is involved in approximately 65% of patients who develop HZO with sight threatening complications including scarring, neurotrophic keratitis, secondary infectious keratitis, and perforation. 2  HZO is associated with a greater incidence of post-herpetic neuralgia (PHN) than other dermatomal HZ distributions. 3  Advancing age has been correlated with increasing incidence and severity of disease. 4  Current CDC/ ACIP recommendations advise zoster vaccine administration to adults 60 and older for the prevention of HZ and has been shown to decrease the incidence of HZ by 51%. 5 PURPOSE: 1) To determine the spectrum of age of diagnosis for patients presenting with HZO. 2). 2) To analyze the clinical course of HZO and to compare the severity of the disease in patients who were 60 years of age or older versus below 60 years at the time of diagnosis. 1. Glynn C. Crockford G, Gavaghan D, Cardno P, Miller J. Epidemiology of Zoster. J R Soc Med 1990; 83: Liesegang TJ. Corneal complications from HZO. Ophthalmology 1985; 92: Pavan-Langston D. Herpes zoster: Antivirals and pain management. Ophthalmology 2008; 115:S13-S Cooper M. The epidemiology of Zoster. Eye 1987; 1: Merck. An overview of herpes zoster/PHN and the SPS for Zostravax. Presentation to ACIP. Feb 2006

Study Characteristics Methods  Retrospective chart review of 112 patients with HZO examined during Data was collected with respect to age at and year of diagnosis, initial treatment, predisposing factors, number of office visits, and duration of follow up. Incidence of flares, pseudodendrite formation, acute pain, PHN, complications and treatments were recorded. The patients were then divided into two groups of ≥60 yrs and <60 yrs and were compared. Definitions  Flare up was defined as any initiation or increase in steroid dosage or potency.  PHN was defined as post herpetic neuralgia after 3 months of onset or post herpetic itch (PHI).  Steroid potency was defined as high, medium, or low using classifications described previously Epstein AJ et al. Risk factors for the first episode of corneal graft rejection in keratoconus. Cornea 2006; 25:

Age at Diagnosis of HZO Age (years) Results

Baseline characteristics Under 60yrs (n= 58) 60 and older (n= 54) Age at dx Mean follow up (months)* Female2828 OD:OS2820 Comp immunity 714 Cancer210 Oral steroids 03 Immunosuppression40 HIV20 No medical history 5140 VA presentation (logMAR)      Acute Pain at presentation 2423  statistically significant p<.05  statistically significant p<.01 *Pts with at least 3 months of follow up  statistically significant p<.05  statistically significant p<.01 Predisposing Conditions Under 60Predisposing Conditions 60 an Over Results

Baseline characteristics Under 60yrs (n= 58) 60 and older (n= 54) Anti viral (oral)<72 hrs 1111 Anti viral (oral)>72 hrs 1823 Anti viral (oral) + topical antiviral 36 Steroid only 67 Topical anti viral only 61 Unknown1512 Treatment at Time of Presentation Patients Under 60 Years Treatment at Time of Presentation Patients 60 Years and Over Results

Change in Visual Acuity from Presentation to 1 year Change in Visual Acuity from Presentation to 3 years Patients Under 60 Patients 60 and Over Patients Under 60 Patients 60 and Over

Visual Acuity at Final Follow Up Visit Change in Visual Acuity Over 3 Year Period Patients Under 60 Patients 60 and Over Patients Under 60 Patients 60 and Over p<.05

Flares per year <60 (n= 54) ≥ 60 (n= 42) All patients* * Patients with at least 3 months of follow up Cumulative Steroid Use Pseudodendrite Incidence

ComplicationsComplications*<60(n=51)≥60(n=42) Corneal melt 23 Perforation21 Secondary infection 2 7  Cataract97 Neurotrophic keratitis 5 17  IOP> IOP>3054 IOP >40 21 Band keratopathy 0 4  PHN/PHI4 16  *Patients with at least 3 months of follow up  p<.05

Surgical Procedures Surgeries * < 60 (n=51) ≥ 60 (n=42) Tarsorrhaphy2 7  Penetrating keratoplasty 73 Glue30 Bandage contact lens 36 Punctal plugs 912 Phacoemulsification45 Glaucoma filtering procedure 01 EDTA chelation 02 Conjunctival flap 11 Lamellar keratectomy 11 Enucleation/ Evisceration 10 * Patients with at least 3 months of follow up  p<.05

Conclusions  Peak incidence of HZO is within years of age in our practice, with equal incidence above and below the age of 60.  Most patients in both age groups did not have co-morbid medical conditions, however cancer appears to have an association with HZ in the older population.  Significant percentage of patients in both groups did not receive adequate antiviral therapy before presentation.  Though most patients in both groups returned to baseline VA, a significant proportion experienced decline in VA, especially in the older age group.  Patients above 60 more commonly were affected by neurotrophic complications and PHN.  Patients below 60 were more affected by pseudodendrites/ late VZV dendriform keratitis.  It appears as though the benefit for HZ vaccine administration may apply to ages below 60.