Eyeworld

Experts warn to tread carefully P erforming refractive sur- gery on a patient with any type of ocular herpes sim- plex virus (HSV)—be it herpes keratitis, stromal keratitis, or iridocyclitis—is a serious gamble. Any trauma to the cornea, as well as exposure to ultraviolet light from the excimer laser used, could reactivate a dormant virus, sparking a domino effect of eye problems in the patient. Reactivation of the virus can in- crease complications from the proce- dure, causing issues such as corneal scarring, loss of vision, secondary glaucoma, and corneal thinning and perforation. But just because it's risky doesn't mean no one does it. Many surgeons simply proceed with caution and choose candidates with care. "In my opinion if there's a known history of herpetic keratitis, I try not to do an elective refractive procedure like PRK or LASIK," said Helen Wu, M.D., assistant professor of ophthalmology, Tufts University School of Medicine, Boston. "That would be the most conservative, and in some people's minds, the most reasonable and safe way to go." But what if the virus has been dormant for a while? What if the cornea looks immaculate? The longer it's been since an outbreak, the better. "I would not operate on anyone who had an episode of active ocular HSV within 1 year of the planned surgery," said Jay S. Pepose, M.D., Ph.D., director, Pepose Vision Insti- tute, St. Louis, and professor of clini- cal ophthalmology, Washington University School of Medicine, St. Louis. "Previous history of stromal HSV increases the risk of recurrent stromal disease over 10 times, and it is this form of ocular HSV that is the most sight threatening." "If I had a patient with a herpes episode 10 years ago and it went away and never came back and the cornea looked perfect—zero haze, zero scar—I think it's reasonable, with proper informed consent, to do refractive surgery," said Christopher J. Rapuano, M.D., co-director, Cornea Service and Refractive Sur- gery Department, Wills Eye Institute, Philadelphia. Determining if patients have herpes simplex and if they do, when their last flare up was isn't always easy. In many cases, the patients themselves are unaware they're in- fected. Symptoms of ocular herpes can be as benign as a red eye resem- bling conjunctivitis, which makes it difficult for individuals to know the difference between everyday pink eye and ocular herpes. "Twenty percent of acute follic- ular conjunctivitis is caused by HSV, and patients may think they had a typical 'pink eye' infection that spontaneously cleared," said Dr. Pepose. "You cannot rely on history alone. The recurrences of HSV are strongly associated with the previ- ous form of HSV, so patients with conditions that may spontaneously resolve may be less frequently aware of their history than patients with recurrent HSV stromal keratitis." Further complicating matters, testing for the virus would be point- less because so many people in the U.S. have been exposed to it in some form, be it oral or ocular. "The tests aren't very good," said Dr. Rapuano. "If I test 100 peo- ple who come to my office, 90% of them will test positive with blood tests for HSV. It just doesn't make any sense to do that." "If patients have a history of cold sores or fever blisters then one should assume that they are infected with HSV, but this does not increase the likelihood of them developing ocular involvement," said Dr. Pepose. What does make sense is check- ing patients' corneal sensitivity, looking for signs of scarring, thin- ning, or neovascularization. "If the corneal nerves are not functioning properly then refractive surgery is extra risky," said Dr. Rapuano. "It increases the risk of poor healing." If you do operate on a patient with a known history of HSV, the doctors recommend putting that pa- tient on prophylactic oral antivirals before, during, and after surgery to prevent a flare up. If a patient has an HSV flare up, oral antivirals are again recommended, as well as topi- cal gels. "Patients with reactivated HSV should be treated with topical 0.15% ganciclovir gel five times daily until the lesion resolves and then three times daily for an additional week," said Dr. Pepose. "Gentle debride- ment may also reduce the HSV anti- gen load. If there was evidence of stromal keratitis, I would add on a topical corticosteroid to the antivi- rals and then slowly taper the corti- costeroid as the inflammatory component subsided." EW Editors' note: The physicians mentioned have no financial interests related to their comments. Contact information Pepose: jpepose@peposevision.com Rapuano: cjrapuano@willseye.org Wu: helenkw@aol.com EW REFRACTIVE SURGERY February 2011 41 by Faith A. Hayden EyeWorld Staff Writer Refractive surgery on patients with herpes simplex virus Performing refractive surgery on a patient with any type of ocular HSV can lead to serious complications Source: Edward J. Holland, M.D. July 2011 Treating continued from page 40 when implanting multifocal IOLs. If greater than 1.5 D is anticipated, I recommend bioptics with LVC at 2 months for the residual cylinder be- cause of greater predictability and re- producibility at these levels of cylinder." If there is more than 2.5 D of cylinder present, Dr. Black said he recommends that the patient avoid multifocal IOLs and consider toric lenses "with or without modified or 'mini' monovision." Going lower Steven J. Dell, M.D., Austin, Texas, easily corrects corneal astigmatism using LRIs in his patients who have 1 D or less. "Over the years, I have found myself treating lower and lower lev- els of astigmatism, particularly in presbyopia-correcting IOL patients," Dr. Dell said. "In many cases, I treat below 0.5 D because this clearly has a beneficial effect on overall per- formance of presbyopia-correcting IOLs." When astigmatism is around 1.5 D or higher, Dr. Dell said it is easier to achieve his and the patient's de- sired result with a toric lens. Many factors go into the decision of which modality fits best with each patient, he said. "A common example is when a patient opts for an accommodating or multifocal IOL where a toric IOL is not an option," Dr. Dell ex- plained. "Toric IOLs are to be used with caution in situations where the IOL is more prone to dislocation, as is the case in pseudoexfoliation pa- tients or in patients with zonular in- stability from any cause." Of course, LRIs also have some limitations. According to Dr. Dell, LRIs may increase neurotrophic dry eye in some patients and should be used with caution in patients who have irregular astigmatism. Also, some patients are poor candidates for any form of astig- matic correction. "In cases where a spherical error is highly likely to occur post-IOL, I sometimes leave the astigmatism un- treated with the anticipation of using laser vision correction post- op," Dr. Dell said. EW Editors' note: Dr. Black has financial interests with Alcon. Dr. Chu has fi- nancial interests with Abbott Medical Optics (AMO, Santa Ana, Calif.) and Bausch & Lomb (Rochester, N.Y.). Dr. Cionni has financial interests with Alcon. Dr. Dell has financial interests with AMO, Alcon, Allergan (Irvine, Calif.), and Bausch & Lomb. Contact information Black: 812-284-0660, scwiak@me.com Chu: 952-835-0965, yrchu@chuvision.com Cionni: rcionni@theeyeinstitute.com Dell: 512-327-7000, sdell@austin.rr.com

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