Herpes Simplex Necrotizing Stromal Keratitis After Femtosecond Laser-Assisted Cataract Surgery With Arcuate Keratotomies: A Case Report.
David Lamas-Francis, Elia de-Esteban-Macineira, Begoña de-Domingo et al.
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Case in brief
An 80-year-old woman with no known history of ocular herpes developed severe keratitis 15 days after uncomplicated femtosecond laser-assisted cataract surgery with paired arcuate keratotomies. Dendritic lesions followed the keratotomy incisions, with stromal infiltrates and necrosis, diffuse endotheliitis, and mild anterior uveitis. Despite initial oral valacyclovir and topical antiviral therapy with corticosteroids, disease progressed to hypopyon, worsening necrosis, and hemorrhagic hyphema. Anterior chamber PCR confirmed HSV-1. After intensive antiviral and adjunctive treatment, including intravenous acyclovir and procedures for complications, inflammation gradually resolved; final best-corrected visual acuity was 0.4 logMAR.
What made this case unusual
The necrotizing HSV-1 keratitis arose along femtosecond arcuate keratotomy wounds in a patient without known prior ocular herpes, and progressed rapidly despite initial antiviral treatment.
Diagnostic / clinical pearl
Dendritic lesions and stromal necrosis aligned with arcuate keratotomy sites after FLACS should prompt consideration of HSV even without a known herpetic history; anterior chamber PCR confirmed the diagnosis in this case.
Why it matters
The case highlights the potential for severe herpetic disease after arcuate keratotomy and the need for early recognition, aggressive antiviral treatment, and careful corticosteroid use.