Faculty Bibliography

Herpes zoster ophthalmicus (HZO) is a common, vision and potentially life-threatening disease caused by the reactivation of the varicella-zoster virus (VZV) in the distribution of the first division of cranial nerve V. Although the rate of herpes zoster increases with age, over half of the people with zoster in general, including HZO, are under age 60. In addition, over 90% of people with zoster are immunocompetent, even though the disease is more common and severe in immunocompromised patients. The incidence of zoster is increasing worldwide for unknown reasons. The epidemiology has not yet been impacted by the zoster vaccine (ZV). The lack of a strong recommendation by physicians for this vaccine is a major barrier to its use. An unresolved dilemma regards the optimum timing for this vaccine. In the USA, the current recommendation by the Centers for Disease Control and Prevention (CDC) is for eligible people age 60 and older, despite its greater efficacy in reducing the incidence of disease and Food and Drug Administration (FDA) approval for age 50-59. Although there is a consensus regarding use of acute high-dose oral antiviral treatment to reduce ocular complications, there is limited evidence for prolonged treatment. The rationale for a proposed randomised controlled trial (RCT) of suppressive antiviral treatment to reduce chronic eye disease and postherpetic neuralgia (PHN) includes evidence that zoster is followed by chronic active VZV infection and similarities between HZO and herpes simplex virus (HSV) eye infection, where this treatment is effective and is the standard of care.

Herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus (VZV) in people who have had chicken pox, usually resulting in a painful, unilateral, dermatomal, vesicular rash. Herpes zoster ophthalmicus occurs when the first division of cranial nerve V is involved. HZ is common, with approximately 1 million new cases per year in the United States, and occurs in 1 in 3 persons. Although the rate of HZ increases with age, over half of all cases occur under the age of 60 years. Complications of herpes zoster ophthalmicus include eye disease, postherpetic neuralgia (PHN), and strokes. VZV has also been found in temporal arteritis biopsies. There is growing evidence that HZ is followed by chronic active VZV infection contributing to these complications. In view of this, and the efficacy of suppressive antiviral treatment in reducing recurrent herpes simplex keratitis, a randomized controlled trial of suppressive valacyclovir to reduce new or worsening anterior segment disease and/or PHN is needed. The zoster vaccine (ZV) is safe and effective in reducing the burden of illness, severity of PHN, and incidence of HZ. It is Centers for Disease Control and Prevention recommended for persons aged 60 years and above without impaired cellular immunity, and Food and Drug Administration approved for those aged 50 and older. It is most effective in preventing HZ in recipients in their 50s. Because of underusage of the ZV, it has not impacted the epidemiology of the disease. Barriers to its use include cost, variable reimbursement, frozen storage, and lack of a strong recommendation by doctors.

OBJECTIVE:: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. METHODS:: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. RESULTS:: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. CONCLUSIONS:: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

OBJECTIVES: The purpose of this study was to develop a consensus regarding the appropriate regimen to evaluate long-term suppressive antiviral treatment to reduce complications from herpes zoster ophthalmicus (HZO) and identify potential study sites. METHODS: In January 2013, a survey of 13 questions was distributed among cornea fellowship directors, board members of the Cornea Society and Ocular Microbiology and Immunology Group, and Kera-net Listserv members. Questions identified respondents' preferred antiviral regimens to administer for chronic or recurrent HZO, gauged the level of interest in participation in a planned randomized clinical trial, and assessed the number of HZO patients treated among specialists in the past year. RESULTS: Of the 171 respondents who completed the questionnaire, the majority identified as Kera-net Listserv members (107 of 171, 63%) and cornea fellowship directors (46 of 171, 27%). First choice of treatment was valacyclovir 500 mg 2 times per day (61 of 171, 36%), followed by acyclovir 800 mg 2 times per day (56 of 171, 33%), and then valacyclovir 1,000 mg daily (26.9%, 46 of 171). Among the choices, famciclovir consistently placed last among all the respondents (7 of 171, 4%). A majority (106 of 171, 62%) of all respondents, including 70% (26 of 37) of U. S. respondents of the high-volume practices, were interested in participating in a future randomized clinical trial evaluating whether treatment with oral antiviral medications for 1 year decreases complications of HZO. CONCLUSIONS: This survey highlights the strong interest in and support for further study of suppressive antiviral treatment regimens to reduce complications of HZO.

Purpose: To evaluate the cornea ulcer microbiology of patients at an urban city hospital. Methods: Corneal ulcer patients examined and cultured were identified retrospectively. The media and stains submitted were assessed, and the microbiology was analyzed. Gram stains were analyzed and correlated with positive cultures. The use of topical antibiotic and/or topical steroid at time of culture was analyzed to correlate with positive results. Results: 114 corneal ulcers were treated over 10 years (1/2004 to 12/2013). 71/114 (62.3%) ulcers were cultured. 68/71 (95.8%) of the cultures submitted were corneal scrapings plated on blood, chocolate, thioglycolate, sabaround's, and slides for gram stains. 3 included KOH stains for fungus. 3/71 submissions were corneal swab with gram stain.17/68 (25%) culture submissions from scrapings were incomplete, missing one of the media plates. 9/71(12.7%) submissions did not include a gram stain. 0/3 corneal swabs yielded a positive result. 24/68 (35.3%) of corneal scraping cultures yielded a positive result, including 1 mixed bacterial and 1 fungal. The most common was pseudomonas aeruginosa 8/68 (11.8%), followed by serratia 4/68, coag negative staph 3/68, and stenotrophomonas maltophilia 2/68. There was one positive result each for Bacillus, strep pneumoniae, MRSA, and beta strep group G. One culture grew both bacillus and coag negative staph. One culture grew Aspergillus. At time of culture, 21 patients were on a topical antibiotic (including the patient whose culture grew Aspergillus), 3 were on a topical steroid, and 2 were on both. Compared to positive cultures in patients not on any medications (14/41 or 24%), positive cultures were found in 6/23 (26%) of patients on topical antibiotic with or without steroids (P=0.849), and 2/3 (66%) of patients on steroid alone (P=0.267). 12/62 (19%) gram stains were positive. 5/5 gram stains that showed an organism had corresponding growth in culture. 8/12 (66.7%) of positive gram stains eventually yielded growth of a microorganism compared to 14/50 (28%) of negative gram stains (P=0.012). 0/3 of KOH stains submitted yielded fungal elements. Conclusions: The majority of ulcers cultured yielded bacteria, with pseudomonas the most common. The use of topical antibiotic or steroid did not statistically affect culture yield. A positive gram stain does correlate with a positive culture yield. However, there is a high frequency of incomplete cultures

PURPOSE:: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. METHODS:: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. RESULTS:: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). CONCLUSIONS:: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.

OBJECTIVE: To further define the spectrum of clinical disease and treatment among patients with herpes zoster ophthalmicus (HZO) and ocular herpes simplex viral (HSV) infection presenting at a large city hospital for the underserved in the United States. METHODS: Retrospective review of medical records of 64 patients (40 HZO and 24 ocular HSV infection) presenting to the Bellevue Hospital Emergency Department for the management of herpetic eye disease for which an ophthalmologic consultation was obtained from January 1, 2006, to December 31, 2011. RESULTS: The mean age of patients with HZO was 51 +/- 15 years (n=40) versus 33 +/- 16 years for patients with ocular HSV infection (n=24; P<0.0001). Overall, 73% of patients with HZO were aged <60 years (n=29 of 40), of whom, 90% (26 of 29) were immunocompetent. The most common decade of onset of HZO was 50 to 59 years (11 of 40, 28%). Four patients with HZO were immunocompromised (n=4 of 40; 10%), with 3 aged <60 years attributable to human immunodeficiency virus (n=3 of 29, 10%). The study included 12 patients eligible to receive the herpes zoster vaccine. None of these patients had a history of vaccination. Of the 24 patients with ocular HSV infection, corneal stromal disease was present in 7 patients and infectious epithelial keratitis in 10 patients. No patients were treated with long-term oral antiviral prophylaxis. CONCLUSIONS: Acute HZO was seen more commonly than ocular HSV infection. Patients with HZO were significantly older than those with ocular HSV infection. Available prevention modalities, such as the vaccine against herpes zoster and long-term oral antiviral therapy to reduce ocular HSV infection recurrence, were underused.

PURPOSE: To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. DESIGN: Prospective interventional cohort study. METHODS: setting: Academic City Hospital, Bellevue Hospital. participants: A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. interventions: The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. main outcome measures: Barriers to administration of the vaccine were evaluated. RESULTS: A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P