Eyeworld

SEP 2014

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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EW FEATURE 62 Phaco and corneal comorbidities September 2014 AT A GLANCE • Patients with a history of herpes simplex virus or herpes zoster virus require special care and monitoring before cataract surgery. • Before cataract surgery in these patients, surgeons aim for an eye that has been free of fl are-ups for at least 3 months. Some surgeons prefer to wait longer if the patient has stromal disease. • Oral antivirals provide prophylaxis and are typically part of the postop regimen. • The Centers for Disease Control and Prevention recommends the herpes zoster vaccine for everyone age 60 and older who is immunocompetent, regardless of previous herpes zoster fl ares. Surgeons generally believe in following this guideline. by Vanessa Caceres EyeWorld Contributing Writer tient will already be using a topical steroidal, a topical nonsteroidal anti-infl ammatory drug, and you're adding something else with a topical antiviral," Dr. Mah said. A topical agent like Zirgan (ganciclovir, Bausch + Lomb, Bridgewater, N.J.) that is dosed 5 times a day would make medication compliance all the more diffi cult, he added. Dr. Mah leans toward waiting to do surgery for at least 6 weeks if the patient has had epithelial disease, but will wait at least 3 months if the patient has a stromal condition. A patient with a history of HSV or HZV immune stromal disease and who is on topical steroids may have a more complicated clinical course 3 months, said Vincent P. de Luise, MD, FACS, assistant clinical profes- sor of ophthalmology, Yale Universi- ty School of Medicine, New Haven, Conn., and adjunct clinical assistant professor of ophthalmology, Weill Cornell Medical College, New York. "It is known that many trig- gers, including cataract surgery, can cause a recurrence of HSV keratitis. In a patient with a history of HSV epithelial disease who has a visually signifi cant cataract and in whom the patient and surgeon are contemplat- ing surgery, the epithelial HSV keratitis should be completely eradicated, and the eye should be white and quiet for at least 3 months before any surgery is performed," Dr. de Luise said. Quieting the eye Dr. de Luise recommends starting oral valacyclovir (Valtrex, GlaxoSmithKline, Brentford, U.K.; 500 mg, twice a day) or oral famciclovir (Famvir, Novartis, Basel, Switzerland; 250 mg twice a day) 1 week preoperatively, and continuing the oral antiviral for several months after surgery. "I'd use either acyclovir 800 mg, twice a day or valacyclovir at 1000 mg or 500 mg, twice a day, or fam- ciclovir 250 mg, twice a day," said Francis Mah, MD, director of cornea and external disease, and co-director of refractive surgery, Scripps Clinic, La Jolla, Calif. "I'd probably avoid using a topical agent as the pa- Surgeons share management strategies I t can be a treatment conun- drum. You have a patient who needs cataract surgery, but he or she has a history of herpes simplex virus (HSV) or herpes zoster virus (HZV). How should you proceed? Your fi rst goal should be to get the eye completely quiet for at least HSV and HZV require careful monitoring before cataract surgery Monthly Pulse Keeping a Pulse on Ophthalmology T he topic of this Monthly Pulse survey was "Phaco and corneal comorbidities." We asked what you would do for a patient with a pterygium and cataract, and about 75% of respondents said they would remove the pterygium fi rst, then perform cataract surgery later. For a patient with a visually signifi cant superfi cial corneal scar and cataract, most respondents would perform cataract surgery only, then refer to a cornea specialist if the vision is still not acceptable. We asked what you would do if a patient presented with visually signifi cant corneal guttae and cataract. Almost half of respondents would perform cataract surgery only, then refer to a cornea specialist if the vision is still not acceptable. Finally, for a patient with a history of herpes simplex virus (HSV) immune stromal keratitis and visually signifi cant cataract, the majority of respondents would put the patient on oral anti-viral prophylaxis for 1 week prior to performing cataract surgery. The second most popular answer was "Put the patient on oral anti-viral prophylaxis for 3–6 months after cataract surgery," followed closely by "Wait for the patient to be HSV disease-free for 6 months prior to performing cataract surgery." Iridocyclitis in herpetic stromal keratitis Source: Francis Mah, MD

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