The risk never diminishes to zero.
“The scariest part is that the first episode can actually be stimulated by just having eye surgery,” Dr. Yeu said.
Surgeons and patients should weigh the risks against the benefits of the surgery under consideration.
“With cataract surgery, you know there’s actually a pathology there,” Dr. Yeu said. “Thus, the benefit of the likely improvement in vision can easily outweigh the risk of stimulating an HSV recurrence, whereas it is more difficult to justify this risk when considering a corneal refractive surgery candidate whose vision could easily worsen by a recurrent keratitis.”
Potentially devastating complications, albeit rare, can include fulminant herpetic keratouveitis with flap necrosis
Even less-severe infections, such as a short-lived course of epithelial keratitis, can lead to suboptimal vision from irregular astigmatism or scarring, she said.
People with HSV infections can be considered good candidates for cataract surgery if their infections have been inactive for at least 6 months, and the cataract extraction could lead to an overall vision improvement. Ultimately, any corneal pathology (corneal scarring or topographic irregularity) can lead to less-than-ideal vision, Dr. Yeu said.
Candidates for corneal refractive surgery, such as LASIK, should not have had an active infection in the past year, evidence of stromal disease, irregular topography, irregular pachymetry maps, or abnormal corneal sensitivity, she added.
For patients who have an inactive HSV infection, she recommended starting prophylaxis a day before surgery and maintaining it for 7 to 14 days afterward.
“If you can carry anti-viral prophylaxis through until they are reduced on their steroids to about once a day, that is a very smart thing to do because steroids themselves can trigger an episode of active viral epithelial keratitis,” Dr. Yeu said.
Prophylaxis anti-viral regimens to consider include valacyclovir 500 mg po BID, acyclovir 400 mg po BID, and topical ganciclovir 0.15% gel to the operative eye. The literature on ganciclovir is sparse, but using the ganciclovir gel as frequently as the steroid drop is used could be a reasonable protocol, Dr. Yeu said.