Zoster Eye Disease Study

The objective of the Zoster Eye Disease Study (ZEDS) is to determine whether prolonged
suppressive oral antiviral treatment with valacyclovir reduces complications of Herpes Zoster
Ophthalmicus (HZO), thereby improving clinical outcomes in this common and potentially
vision- and life-threatening disease. There are 1,000,000 new cases of Herpes Zoster (HZ) per
year in the USA, with 10-20% being HZO.

Specific AIMS

Primary Aim: The primary aim of this double-masked, placebo controlled multicenter randomized
clinical trial will test the hypothesis that suppressive antiviral treatment for 12 months
with oral valacyclovir 1000 mg daily reduces the rate of new or worsening dendriform
epithelial keratitis, stromal keratitis, endothelial keratitis or iritis compared to placebo,
at 12 months as the primary endpoint, and at 18 months including 6 months of follow-up after
treatment, as a secondary endpoint, in patients with HZO who have had an episode of one of
these disease manifestations during the year prior to enrollment.

Secondary AIM: The second aim is to test the hypothesis that suppressive treatment for 12
months with oral valacyclovir 1000 mg daily reduces the severity and duration of postherpetic
neuralgia (PHN), compared to placebo, at 12 months and at 18 months as secondary endpoints,
in similar patients with HZO. PHN is a debilitating chronic pain syndrome that negatively
impacts quality of life, especially in elderly patients.

The study will enroll immunocompetent patients age 18 years and older who have HZO diagnosed
at variable times in the past, with these types of active anterior segment ocular segment
disease within the past year. Eligible patients will be randomized in a 1:1 ratio to
long-term suppressive treatment with oral valacyclovir 1000 mg daily or placebo for 12
months, plus usual ophthalmic care, and followed every 3 months for a total of 18 months, to
determine outcomes of new or worsening dendriform epithelial keratitis, stromal keratitis,
endothelial keratitis or iritis and/or severity and duration of PHN during 12 months of
treatment and for 6 months following treatment discontinuation. The results with regard to
PHN may be applicable to HZ in other locations. If suppressive valacyclovir treatment is
determined to be effective, the potentially devastating disease burden of HZO and HZ may be
reduced for patients, as well as the annual costs to society, estimated in the USA to be one
billion dollars.

PARTICIPANT INCLUSION CRITERIA

To be eligible for study participation, an individual must meet all of the following
criteria:

1. Ability to understand, and willingness and ability to read and sign, the informed
consent form.

2. Ability to understand and follow instructions and study procedures.

3. Willingness to comply with all study procedures and be available for the duration of
the study.

4. Ability to take oral medication, and are willing to adhere to study medication
regimen.

5. Age 18 years or older.

6. Diagnosed with HZO in one eye based on both of these criteria:

1. History of characteristic unilateral, usually vesicular, rash in the dermatomal
distribution of cranial nerve V1.

2. Medical record documentation of an episode of active dendriform epithelial
keratitis, stromal keratitis, endothelial keratitis, and/or iritis due to HZO
within the preceding year. This episode of active anterior segment ocular disease
may be due to HZO of recent onset (within the preceding 6 months); or chronic HZO
(with onset six or more months ago); may be new, worsening, or recurrent disease
after a period of inactivity; and may occur after medication was reduced.

i. Study participants with chronic HZO must be on a stable treatment regimen and off
antivirals for at least 30 days before enrollment. Study participants with chronic HZO
who do not meet this criterion may be rescreened, if they are able to meet this
criterion within 3 months after the study visit. (This is not a requirement for study
participants with recent onset HZO, who may be enrolled at any time, preferably after
completing recommended acute antiviral treatment, if prescribed, is completed).

7. For females with reproductive potential, willingness to use highly effective
contraception (e.g., hormonal contraception, barrier contraception, intrauterine
device, or abstinence).

PARTICIPANT EXCLUSION CRITERIA

An individual who meets any of the following criteria will be excluded from participation
in this study:

1. History of immunocompromised status as defined by current CDC contraindications for
the vaccine against zoster (44).

1. Study participants who are diagnosed with leukemia, lymphomas or other malignant
neoplasms affecting bone marrow or lymphatic system, unless leukemia in remission
and off chemotherapy for at least 3 months.

2. Study participants who are diagnosed with Acquired Immune Deficiency Syndrome
(AIDS) or presents with other clinical manifestations of Human Immunodeficiency
virus (HIV) including CD4 count of ≤ 200 cells/ml.

3. Study participants on immunosuppressive therapy including:

i. High-dose corticosteroids (greater than equivalent of prednisone 20 mg/day within 1
month) ii. Chemotherapy, other than low dose used for treatment of immune-mediated
diseases within 3 months iii. Study participants receiving recombinant human immune
mediators and immune modulators, especially antitumor necrosis agents, within 1 month
prior to enrollment d. Study participants with unspecified cellular immunodeficiency.
e. Study participants with history of hematopoietic stem cell transplantation.

2. Medical history of a systemic disease and thought likely to meet one of the exclusion
criteria listed in exclusion criterion #1 during the 18-month study period.

3. Renal insufficiency:

1. Requires dialysis or has history of renal transplant or

2. eGFR less than 45, determined within 30 days preceding enrollment.

4. Allergy or adverse reaction to valacyclovir or acyclovir.

5. History of vaccination against zoster within one month prior to enrollment. Study
participants who meet this exclusion criterion may be rescreened. If the study
participant receives the Herpes Zoster Subunit vaccine (Recombinant Zoster Vaccine
(RZV), Shingrix), rescreening should take place one month after the second required
dose of the vaccine.

6. Keratorefractive surgery, other than limbal relaxing incisions or astigmatic
keratotomies at the time of cataract surgery, within 5 years of enrollment, or
keratoplasty of the involved eye with zoster.

7. On systemic antivirals with activity against herpes within the past 30 days, including
acyclovir, valacyclovir, or famciclovir, for any reason except for treatment of acute
HZO, including investigational drug trial.

8. History of another condition that may require treatment with one of these three
antivirals listed above in exclusion criterion #7, during the course of the study;
study participants who require chronic suppressive antiviral treatment with these
medications will be excluded.

9. Sexually active women who are pregnant, nursing, or in their reproductive years who do
not agree to use contraception during the 1-year treatment period.

10. Incarceration

11. Any condition or circumstance that in the opinion of the study investigator, would
place the study participant in increased risk or affect his/her full compliance or
completion of the study.

12. Participation in a clinical study testing a drug, biologic, device or other
intervention within the last 30 days from enrollment visit. Study participants who
meet this criterion may be rescreened.