Reply : Cataract surgery in herpes simplex virus ocular disease.

Abstract

We thank Cho et al. for their comment on our study and for sharing their experience in this area. We read with interest their study on epithelial keratitis after cataract surgery where the authors found that of 666 patients undergoing cataract surgery, 15 developed postoperative keratitis and 11 of those tested positive for HSV polymerase chain reaction. The authors observed that all patients who developed HSV keratitis had a temporal corneal incision location despite only 37% (247/666) of the total cohort having temporal incisions.1 In our institution, most of the surgeons routinely perform temporal clear corneal incisions. Within our cohort with HSV, temporal incisions were the most common, and unfortunately, we do not have sufficient power to compare temporal incisions with other sites. A laboratory study on the anatomy of the innervation of human cornea observed approximately 44 nerve bundles entering the cornea, which are evenly distributed around the limbus. The study did not find a preferential concentration of nerve bundles in the 3-o'clock and 9-o'clock meridians.2 In addition, a randomized (contralateral-eye) controlled study comparing the effect of hinge position on corneal sensation and dry eye after laser in situ keratomileusis found no difference between superior and nasal hinge positions.3 This evidence would suggest that innervation density alone may not affect the risk for HSV recurrence; however, future randomized studies comparing temporal and superior corneal incisions in patients with previous HSV keratitis undergoing cataract surgery would be of great interest. In summary, both our study and that by Cho et al. emphasize that cataract surgeons should be aware of the risk for HSV ocular disease after cataract surgery, and careful perioperative planning is necessary in those with a history of HSV ocular disease. Maximizing the preoperative disease quiescence time, using appropriate perioperative antiviral prophylaxis, and close monitoring for disease recurrence postoperatively are key for ensuring the best outcomes in patients.