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EW FEATURE tent patients age 50 or over, even if they have a previous history of herpes zoster, Dr. de Luise said. If the latter is the case, then the patient should wait at least 6 months before getting the vaccine, he added. "The vaccination issue was controversial in the past," Dr. Jeng said. "More recent data suggest they should get the vaccine, so I would follow that." He cited a study published last year in the Journal of Infectious Disease, which found that the Center for Disease Control and Prevention's current guideline to vaccinate everyone over age 60 regardless of herpes zoster history is a safe recommendation. EW Reference 1. Morrison VA, Oxman MN, Levin MJ, et al. Safety of zoster vaccine in older adults following documented herpes zoster. J Infect Dis. 2013;208:559–563. Editors' note: Dr. Mah has fi nancial interests with Alcon (Fort Worth, Texas), Allergan, and Bausch + Lomb. The other physicians have no fi nancial interests related to their comments. Contact information de Luise: eyemusic73@gmail.com Deng: deng@jsei.ucla.edu Jeng: bjeng@som.umaryland.edu Mah: Mah.Francis@Scrippshealth.org before cataract surgery. "It's import- ant that infl ammation in these pa- tients is adequately controlled for a minimum of 3 to 6 months prior to surgery," said Sophie X. Deng, MD, PhD, associate professor of ophthal- mology, cornea division, Jules Stein Eye Institute, Los Angeles. Dr. Deng will start patients on acyclovir 400 mg twice daily or for 2 to 3 days preoperatively or continue them if they're already on it and maintain that dosing for 6 to even 12 months. "I would also continue the patient on the higher dose of topical steroids such as Pred Forte [prednisolone, Allergan, Irvine, Calif.] 4 times a day for 1 month after surgery before starting a very slow taper," she said. "Stromal disease is a little more complicated because it's a deeper and more serious disease," said Bennie H. Jeng, MD, professor and chair, Department of Ophthalmol- ogy and Visual Sciences, University of Maryland School of Medicine, Baltimore. "If the patient is main- tained on topical steroids, you want to make sure they're on the lowest possible dose to control their infl am- mation." Dr. Jeng fi nds the lowest toler- able dose with some trial and error and then aims to keep the eye quiet for at least 3 months before surgery. "I then treat with oral acyclovir preoperatively just like I would for active disease with the dosage being doubled for zoster disease. After that, I will aggressively treat with steroids postoperatively. I'd probably start the patient on them every 2 hours instead of my normal routine of 4 times a day," he said. It is important that your medication regimen for the uveitis patient undergoing cataract surgery targets the risk for ocular infections, Dr. Mah said. "You want to make sure you don't get behind the eight ball from an infection standpoint," he said. Another risk to monitor for in HSV or HZV patients is a neu- rotrophic cornea, Dr. Jeng said. "If you do cataract surgery, it can cause more issues with that." In addition to waiting until the eye is quiet and managing with oral antivirals, Dr. de Luise recommends the preemptive use of topical carbon anhydrase inhibitors and topical alpha adrenergics to blunt any immediate postop IOP spikes. "Topical prostaglandins should be avoided since they are pro- infl ammatory," he said. Prophylaxis for HSV and no ocular signs Treatment approaches for patients with previous HSV ulcers but no ocular signs can vary. Dr. Jeng said he would watch these patients a little more closely but not have them follow a specif- ic regimen, although he has a low threshold for prophylaxing. Dr. Mah will sometimes pre- scribe oral antivirals. "If the patient brings it up or if there's a fairly strong history, I'd probably recom- mend prophylaxis because with the oral agents, the side effects are pretty mild compared to the possible com- plications," he said. Dr. de Luise also prefers to err on the side of prophylaxis. "A recent history of oral HSV vesicula- tion implies the possibility of HSV viremia," he said. "Since the toxicity and morbidity of oral antivirals in patients with normal renal function is very low, the recommendation would be to employ oral antiviral prophylaxis." To vaccinate or not to vaccinate? Surgeons weighed in on whether they recommend the Zostavax vaccine (zoster vaccine live, Merck, Whitehouse Station, N.J.) for patients who have had shingles in their V1 region. "In the immunocompetent host, herpes zoster creates a potent T-cell immune response, which should last for years. It's therefore not necessary for the patient to be given the Zostavax vaccine," Dr. de Luise said. However, the vaccine is recommended for immunocompe- 63 September 2014 Phaco and corneal comorbidities EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Poll size: 262

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