Don’t rule out HSV patients for refractive surgery

August 26, 2016
Marc R. Bloomenstein, OD, FAAO

The longer the time since the last outbreak, the better

I am staunch supporter of refractive surgery. In fact, in my evaluation of potential candidates for refractive surgery I boldly express that every patient can have refractive surgery. Yes, I said it. Everyone can lie down, expose the stromal tissue, and have a laser reshape the tissue for the betterment of visual acuity-or not.

Not every patient is going to get a great result. The caveat to the “everyone is welcome to the refractive party” is that not everyone is an ideal candidate. When we preselect these patients, it is important to filter out those patients who are potential high risk. Through the years, we have really honed in on those patients.

However, we are wrongly biased against one subset of our population-those with herpes simplex virus (HSV). I am speaking to my patients who have any type of ocular herpetic virus. Let’s support those patients who have herpetic virus and want to liberate themselves from glasses or contact lenses.

Understanding HSV
It is not a secret that corneal refractive surgery induces trauma to the cornea, plus it requires exposure to ultraviolet light which potentially can reactivate a dormant virus. The key word in that sentence is “potential” because it is not a certainty that the virus will be set into motion.

More to the point, reactivation of the virus can increase complications from the procedure, creating problems such as corneal scarring, loss of vision, secondary glaucoma, and corneal thinning and perforation.

Research has shown that strictly having the dormant virus does not prompt the activation process. The causes of reactivation are uncertain, but several potential triggers have been documented. Changes in the immune system during menstruation may play a role in HSV-1 reactivation.1

Concurrent infections, such as viral upper respiratory tract infection or other febrile diseases, can cause outbreaks. Reactivation due to other infections is the likely source of the historic terms “cold sore” and “fever blister.”

Other identified triggers include local injury to the face, lips, eyes, or mouth; trauma; surgery; radiotherapy; and exposure to wind, ultraviolet light, or sunlight.1,2

 


The frequency and severity of recurrent outbreaks varies greatly among people. Genetics may play a role in the frequency of cold sore outbreaks. An area of human chromosome 21 that includes six genes has been linked to frequent oral herpes outbreaks.

An immunity to the virus is built over time. Most infected individuals experience fewer outbreaks, and outbreak symptoms often become less severe.

After several years, some people become perpetually asymptomatic and no longer experience outbreaks, though they may still be contagious to others. Immunocompromised individuals may experience longer, more frequent, and more severe episodes.2

Outbreaks may occur at the original site of the infection or in proximity to nerve endings that reach out from the infected ganglia.

The herpetic eye and surgery

This erratic and inconsistent activation lends this condition to a proceed with caution approach. Clinicians can institute a protocol to prophylactically prepare the eye for the insult that surgery may initiate.

However, with modern advancements in anti-viral medications and the profound positive effect that refractive surgery has on patients, there needs to be a risk/reward evaluation.

There is a small but growing body of literature that seems to support my theory that the judicious use of oral antivirals prior to surgery and the initiation of topical antiviral medications during the post-operative period could lend itself to avoidance of any activation and significantly reduces the risk of HSV reactivation in both animal models and in clinical practice.3,4

Twice daily injections of acyclovir, beginning one day prior to LASIK surgery and extending seven days, were found to significantly reduce the incidence of HSV reactivation and the number of days of viral shedding in rabbits.

In several small case studies of LASIK in patients with a history of herpetic keratitis, perioperative antiviral treatment was administered, and no patient developed reactivation of ocular HSV. All patients had been free of ocular symptoms for at least one year at the time of surgery.3

In a retrospective study of 48 LASIK patients with a history of ocular herpes infection,13 received a perioperative antiviral therapy. None of the patients in the study developed reactivation of HSV keratitis during the follow-up window.4

 

 

Managing a herpetic refractive patient is not much different than managing a patient who is diabetic and undergoing cataract surgery-you prepare for the worst and hope for the best. Recently, a 67-year-old post-cataract patient was evaluated for an uncorrected myopic astigmatism.

The patient had a Tecnis (Abbott) lens and was disappointed that he was unable to utilize its full functionality. After evaluating the patient and preparing all the testing, he was deemed a great candidate to undergo PRK.

At his one-day follow-up, the eye was following the typical PRK redness, abrasion, and reduced acuity of 20/80 with a bandage contact lens appliced.

However at the one-week follow-up, traditionally a visit filled with anticipatory optimism, I was treated with an angry red eye of 20/200 vision. The patient clearly had a reactivation of a dormant virus. When questioned again about any previous infections, the patient still was unaware that he had ever been diagnosed or previously had a viral infection.

A good rule of thumb, as stated earlier, follows that the greater lapse of time between active viral events should prove to be a good deterrent of activation of the latent virus.

This patient continued the steroid; however, I was aggressive in adding Zirgan (gangcyclovir ophthalmic gel) 0.15%, Bausch + Lomb) every two hours and copious artificial tears. The dendrite healed without any sequelae, and acuity after three weeks was 20/25 without correction.  

Having a previous viral infection should not limit you from considering refractive surgery for a patient; rather, it should allow you to manage the patient more efficiently.

Adopt a regimen with your surgeon, start the process before the procedure (oral antivirals, topical prophylaxis, or a combination of both), and be the watchful patient advocate that we are trained to be postoperatively.

Any viral infection could rear its ugly head following refractive surgery, or cataract surgery for that matter. Talk to the patient about the risks and benefits, engage him in the process, and allow him to make the ultimate decision.

References:

1. Segal AL, Katcher AH, Brightman VJ, Miller MF (1974). Recurrent herpes labialis, recurrent aphthous ulcers, and the menstrual cycle. J Dent Res. 1974 Jul-Aug;53(4):797-803.

2. Ichihashi M, Nagai H, Matsunaga K. Sunlight is an important causative factor of recurrent herpes simplex. Cutis. 2004 Nov;74(5 Suppl):14-8.

3. Jarade EF, Tabbara KF. Laser in situ keratomileusis in eyes with inactive herpetic keratitis. Am J Ophthalmol. 2001 Nov;132(5):779-80.
4. de Rojas Silva V, Rodriguez-Conde R, Cobo-Soriano R, Beltrán J, Llovet F, Baviera J. Laser in situ keratomileusis in patients with a history of ocular herpes. J Cataract Refract Surg. 2007 Nov;33(11):1855-9.