LASIK stromal versus epithelial herpetic keratitis

Abstract

The title of the article by de Rojas Silva et al.1 includes the general term “ocular herpes,” which may include blepharitis, conjunctivitis, epithelial keratitis, stromal keratitis, endotheliitis, and even chorioretinitis and optic neuritis. The inclusion of many variants of ocular herpes in the study and the absence of eyes with stromal keratitis is important to emphasize, particularly when the major concern of refractive surgeons has been stromal disease in patients with a history of ocular herpes. Cases of herpes reactivation after excimer laser surgery have included patients with stromal involvement and have involved severe complications, such as corneal perforation.2,3 I think the favorable results of de Rojas Silva et al. may largely be due to the absence of stromal involvement in their study population, which included, for example, 17 cases of herpes blepharitis only and 28 eyes with herpetic keratitis with purely epithelial involvement. Reports of recurrence of herpetic keratitis after cataract surgery4 and intravitreal injection of triamcinolone acetonide5 in patients with prior stromal keratitis reinforce the notion that surgical trauma and steroids may play a role in recurrent disease. If a patient experiences epithelial herpetic keratitis soon after LASIK, steroids should be discontinued until the epithelial defect has healed completely, as the clinical course in an operated eye and recent frequent use of topical steroids can be unpredictable.3 In conclusion, the risk for herpetic disease recurrence discussed in the study by de Rojas Silva et al. needs to be carefully interpreted in the context of nonstromal herpetic keratitis. The study does not address the risk for recurrent herpetic keratitis after LASIK in eyes with previous stromal keratitis, and it still seems wise to avoid LASIK in such patients.