Cataract surgery in herpes simplex virus ocular disease

Clinical strategies to prevent recurrence of Herpes simplex and Herpes zoster following ocular surgery: A comprehensive review with practical guidelines

Recurrences of herpetic infections following intraocular surgeries pose a threat to optimal surgical outcomes. The high prevalence of herpetic diseases require ophthalmologists to be familiar with the special measures in the surgery of these patients. A thorough preoperative assessment and meticulous postoperative surveillance should be tailored for each patient, depending on the surgery and the risk of virus reactivation. We compile the relevant evidence in the literature and provide a comprehensive review of the preoperative assessment and postoperative diagnostic clues and management of the herpetic infections following different types of intraocular surgeries, including cataract surgery, keratoplasty, corneal crosslinking, glaucoma, and refractive surgeries.

Recurrence of herpetic keratouveitis following cataract surgery

PURPOSE

Herpetic eye disease (HED) is a leading cause of infectious vision loss worldwide. Cataract surgery is known to be implicated in triggering the recurrence of herpes keratouveitis. This study evaluates the current evidence on the association between HED and cataract surgery, focusing on the risk factors and potential pathogenic mechanisms and preventive strategies involved with reactivation or new-onset herpes-related keratitis, uveitis, or keratouveitis.

METHODS

A comprehensive search of databases (Cinahl, Embase, Scopus, ProQuest, Web of Science, and PubMed) was conducted to identify articles describing the association between new onset or reactivation of HED after cataract surgery up to March 2024. A total of 24 studies were included.

RESULTS

The heterogeneity of the studies precluded systematic analysis. However, the findings suggest that the herpetic recurrence rate, mainly in the form of keratitis, after cataract surgery is high (approximately 40%), mostly occurring ≤ 2 years after surgery, and can be influenced by factors such as topical corticosteroids, the quiescent time before surgery, and history of prior recurrences, and the patient's comorbidities, including diabetes and atopy. The current evidence for prescribing perioperative HED prophylaxis is of inadequate quality.

CONCLUSIONS

Available evidence suggests that herpetic recurrences tend to occur in the first two years after cataract surgery. A longer quiescent time before surgery might reduce the risk of recurrence. Prospective studies analyzing the effects of perioperative prophylaxis are needed.

Bleb Associated Xen Gel Stent Endophthalmitis: A Case Report and Review of Literature

PURPOSE

To report a case of a unique late complication of the Xen gel stent, stent-related endophthalmitis was preceded by flattening of the bleb.

CASE REPORT

A 63-year-old female was presented with late-onset endophthalmitis preceded by flattening of the bleb two years post-insertion of Xen gel stent. B-scan of the posterior chamber revealed vitritis and hyaloid condensation, with no viral, fungal, or bacterial pathologies identified on anterior chamber tap. The patient's eye responded to injections of intravitreal antibiotics.

CONCLUSION

Endophthalmitis can occur as late as 2 years after implantation of glaucoma drainage device implants (GDIs) like the Xen gel stent if bleb flattening or leaking leads to contact of the stent with the conjunctiva. Therefore, in case of blebs getting flat, ophthalmologists should watch them more often. Intravitreal antibiotics may also be effective rather than surgical removal in the case of a non-eroded stent complicated by endophthalmitis.

Combined versus sequential penetrating keratoplasty and cataract surgery for herpes simplex keratitis: a retrospective study

Purpose

To compare the surgical outcomes of combined penetrating keratoplasty (PK) and cataract surgery with those of sequential surgery (cataract surgery after PK) for herpes simplex keratitis (HSK).

Methods

The medical records of consecutive patients diagnosed with HSK who underwent combined or sequential PK and cataract surgery in active and stable stages between June 2015 and June 2022 were reviewed retrospectively. Complications, graft survival, endothelial cell density (ECD), and final BCVA were compared and analyzed between both surgical methods in each stage.

Results

A total of 171 eyes of 171 patients were enrolled, including active stage (69 combined, 46 sequential) and stable stage (34 combined, 22 sequential). The average follow up was 24.2 ± 15.8 months (range, 3 months - 48 months). The final BCVA had obvious improvement and the postoperative ECD was not different in combined and sequential groups of each stage. In sequential group of active stage, 66.7% of persistent epithelial defects and 50% of HSK recurrence occurred within 3 months after cataract surgery; nevertheless, compared to that in sequential group, capsular rupture (p = 0.021), persistent epithelial defects (p = 0.027), and HSK recurrence (p = 0.035) occurred more frequently in combined group, leading to a lower graft survival rate (p = 0.045); at the last visit, 46.4 and 67.4% of grafts remained clear in combined and sequential groups, respectively. By contrary, 82.4 and 50.0% of grafts remained clear in stable stages of combined and sequential groups at the last visit, respectively, and a higher graft survival rate was observed in combined group (p = 0.030).

Conclusion

Although the postoperative ECD is not different between two surgical groups in each stage, sequential surgery in active stage of HSK seems to have advantages in less complications and higher graft survival rate, whereas combined surgery in stable stage has a better outcome than that in sequential surgery.

Acute-Onset Postoperative Herpetic Endophthalmitis: A Case Report

Herpes simplex virus uveitis without corneal reactivation is more frequent than previously thought. Although herpes simplex virus has been implicated as a cause of postoperative uveitis and endophthalmitis, it has not been reported as a cause of acute postoperative endophthalmitis within the early postoperative period, specifically within one week following cataract extraction. A 55-year-old man with vascularized irregular central disc-shaped stromal corneal opacity with complicated cataracts underwent cataract surgery. Intraoperatively, there was posterior capsular rent, requiring anterior vitrectomy. On postoperative day three, the patient had an increase in inflammation in the anterior chamber (grade 4+) with marked vitreous haze (grade 4). Vitreous taps were negative for bacteria and fungi, and despite intravitreal injections of vancomycin and ceftazidime, the patient had worsening of inflammation with increasing exudates and the appearance of the fibrinous membrane in the anterior chamber. Polymerase chain reaction (PCR) of aqueous and vitreous samples at this point of time yielded positive serology for herpes viral DNA, and the patient was started on oral valacyclovir. The ocular inflammation resolved soon after switching to oral valacyclovir. Typical acute postoperative endophthalmitis starts two to seven days after surgery, and the most common isolate in vitreous biopsies is coagulase-negative staphylococci. We report a rare case of acute-onset herpetic endophthalmitis presenting within 72 hours following cataract surgery for a complicated cataract in a patient with a history of pre-existing healed viral keratitis. Our case highlights that a suspicion of viral endophthalmitis should be kept in mind as a cause of acute-onset post-cataract surgery endophthalmitis, especially in cases of surgery that fail to yield a positive result on Gram's stain, culture or PCR for bacteria and fungi.

Cataract Surgery in Uveitis: Risk Factors, Outcomes, and Complications

PURPOSE

To determine the outcomes of cataract surgery in eyes with uveitis, including the rates of intraoperative and postoperative complications, as well as predictors of visual outcomes.

DESIGN

Retrospective observational cohort study.

METHODS

Setting: Tertiary public hospital setting in Auckland, New Zealand, between 2008 and 2020.

STUDY POPULATION

Patients who underwent cataract surgery following a diagnosis of uveitis.Main observation Procedures: Additional intraoperative procedures, intraoperative and postoperative complications, and postoperative visual outcomes and complications.

RESULTS

471 eyes of 371 subjects were included. Median duration of uveitis prior to cataract surgery was 3.0 years (interquartile range [IQR] 5.2) and median period of quiescence prior to surgery was 1.0 years (IQR 1.5). Additional procedures (posterior synechiae peel [32.3%] and vision blue [18.1%]) were common. Intraoperative complications occurred in 32 eyes (6.8%). Consultants were the primary surgeons in the majority (82.5%) of operations. By 12 months, visual acuity was 20/50 or better in 248 eyes (79.7%). The most common postoperative complication was uveitis flare, occurring in 56.5%. On Cox proportional hazards analysis, time quiescent was associated with reduced risk of flare (HR 0.794, P = .003). Postoperative cystoid macular edema (CME) developed in 45 eyes (9.6%), with no significant predictors identified on multivariate analysis.

CONCLUSIONS

Cataract surgery in uveitis is complex. In the hands of the surgically experienced, rates of intraoperative complications are low. The primary challenge is managing postoperative care as we report a high rate of uveitis relapse and CME. Careful monitoring is important as complications can be unpredictable and occur later than expected.

Outcomes and prognostic factors of cataract surgery in cytomegalovirus-related anterior uveitis

PURPOSE

To evaluate the outcomes of cataract surgery in patients with cytomegalovirus (CMV) anterior uveitis and factors associated with final visual outcome.

SETTING

Hong Kong Eye Hospital, Hong Kong.

DESIGN

Retrospective case series.

METHODS

History, clinical characteristics, corrected distance visual acuity (CDVA), medications, and complications of CMV anterior uveitic eyes that underwent cataract surgery between 2010 and 2020 were reviewed.

RESULTS

This study included 26 eyes of 26 patients undergoing phacoemulsification. The median duration of disease was 4.8 years, and the median quiescent period preoperatively was 2.3 years. None required pupil manipulation or had significant intraoperative complications. The median CDVA improved from 20/100 (interquartile range [IQR] 20/200 to 20/50) preoperatively to 20/30 (IQR 20/40 to 20/25) at 1 year and 20/35 (IQR 20/50 to 20/30) at the last follow-up at a median of 4.9 years postoperatively ( P < .001). CDVA improved in 19 eyes (73.1%) and was ≥20/40 in 18 eyes (69.2%). In the multivariate regression model, preoperative use of topical 0.15% ganciclovir (β = 0.33, 95% CI 0.17 to 0.48, P < .001) and adjunctive intraoperative intracameral dexamethasone 0.4 mg (β = 0.19, 95% CI 0.01 to 0.36, P = .043) were associated with a better final CDVA. Loss of CDVA and poor postoperative CDVA visual acuity were mostly attributed to uveitic glaucoma, but preoperative glaucoma or the number of antiglaucoma medications did not affect final CDVA.

CONCLUSIONS

Cataract surgery in eyes with CMV anterior uveitis was safe and CDVA significantly improved and remained sustained postoperatively. Topical ganciclovir 0.15% preoperatively and intracameral corticosteroid intraoperatively seem to maximize the final visual outcome.

Herpetic uveitis caused by herpes simplex virus after cataract surgery in a patient without prior viral keratitis or uveitis: a case report

Background

To report a case of herpetic uveitis caused by herpes simplex virus after cataract surgery in a patient without prior viral keratitis or uveitis.

Case presentation

A 70-year-old female was referred to our clinic with a 16-day history of acute blurry vision with painful redness in the right eye. She accepted cataract surgery for the right eye ten days before initial of ocular symptoms. There was significant inflammation in anterior chamber of the right eye. Retina exam showed moderate dense vitreous opacity but not necrotic or focal retinal lesion in the right eye. The aqueous humor collected from the right eye was positive for herpes simplex virus (HSV) DNA by PCR. The diagnosis of herpetic uveitis in the right eye was made due to clinical presentations and aqueous humor examination.

Conclusion

Herpetic virus reactivation might occasionally occur after intraocular surgery in patients without prior ocular viral diseases, inducing atypical postoperative intraocular inflammation.