Herpes simplex keratitis after LASIK.

To the Editor: Reactivation of latent herpes simplex virus (HSV) has been described following radial keratotomy (RK) and following photorefractive keratectomy (PRK).1-4 Recently, one of my patients experienced such a complication 1 day after LASIK for hyperopia. The patient was a 60-year old caucasian female who had undergone 16-incision RK for myopia in her left eye elsewhere 10 years previously. She stated that she did quite well for a number of years, using the RK eye for distance vision and her unoperated eye for near vision. Two years after the RK, she developed herpes simplex keratitis that resolved without sequelae on topical medications over several days. Approximately 7 years after RK surgery she began to experience a hyperopic shift. On examination 10 years after RK surgery, her uncorrected visual acuity was count fingers in both eyes. Spectaclecorrected visual acuity was 20/20 in her right eye and 20/30 in her left eye with a spherical equivalent refraction of 2.00 1.75 x 160 in her right eye and +3.50 0.50 x 55 in her left eye. A well-centered 16incision RK was present in her right eye with a 3 mm clear zone. The patient opted for hyperopic LASIK despite the theoretical risk of reactivation of the herpes simplex keratitis. Beginning 1 day after surgery, the patient was treated with prophylactic low dose oral famcyclovir (125 mg p.o. tid). Hyperopic LASIK was performed without incident using the Hansatome (180 m ablation head) and the VISX Star excimer laser (9.0 mm outer annulus of the ablation zone). On the morning of postoperative day 1, uncorrected and spectacle-corrected visual acuity was in her left eye was 20/70, and multiple epithelial dendritic lesions were evident. The flap was not edematous, and its wound edges demonstrated only faint staining. The patient was started on viroptic every 2 hours while awake to the left eye, and the famcyclovir was increased to 375 mg p.o. tid. Aggressive lubrication with non-preserved artificial tears was encouraged. By postoperative day 3, the patients uncorrected visual acuity had improved to 20/20, and the dendrites had regressed substantially. Over the following week, the viroptic was tapered but she continued the famcyclovir 375 mg p.o. tid. At 2 weeks postoperatively, the famcyclovir was stopped because she experienced gastrointestinal upset. One month after LASIK, she was off all medications and her uncorrected visual acuity remained 20/20 in her left eye. Manifest spherical equivalent refraction was +0.25 0.75 x 165. There was no evidence of corneal scarring other than the well-healed RK incisions and flap edges were barely visible. Either the trauma of the lamellar dissection or the ultraviolet light of the excimer laser was likely responsible for the reactivation of the herpes simplex keratitis in this patient. More aggressive preoperative prophylaxis (higher dose famcyclovir, perhaps combined with viroptic and artificial tears) could have possibly helped avoid this complication. It was encouraging, nonetheless, that the flap tolerated the topical antiviral medication and that the short-term visual outcome appears excellent.