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Comparative outcomes of ocular surgery in patients with a history of herpes simplex virus: A prospective cohort study of 125 patients
*Corresponding author: Bansi Wade, Department of Ophthalmology, Jamia Islamia Ishaatul Uloom’s Indian Institute of Medical Science and Research, Jalna, Maharashtra, India. bansiwade@yahoo.in
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Received: ,
Accepted: ,
How to cite this article: Wade B. Comparative outcomes of ocular surgery in patients with a history of herpes simplex virus: A prospective cohort study of 125 patients. East Eye. 2025;1:17–19. doi: 10.25259/TEE_4_2025
Abstract
ABSTRACT
Objectives: To compare surgical outcomes in patients with a known history of ocular herpes simplex virus (HSV) who received prophylactic antiviral treatment versus those who did not.
Material and Methods: A prospective cohort study of 125 patients undergoing ocular surgery (cataract, corneal graft, or glaucoma surgery) with prior HSV ocular infection history. Patients were divided into two groups: Group A (n = 65) received antiviral prophylaxis (oral acyclovir), while Group B (n = 60) received no prophylaxis. Outcomes measured included HSV recurrence, graft rejection, inflammation, and visual acuity post-operatively over 12 months. An HSV diagnosis was made based on documented clinical history, signs of past HSV ocular disease, or past use of antivirals with a positive response.
Results: HSV recurrence occurred in 4.6% of Group A versus 21.7% in Group B (p < 0.01). Significant inflammation occurred in 6.1% of Group A versus 23.3% of Group B (p < 0.01). Mean improvement in best-corrected visual acuity was better in Group A (+0.31 logMAR) versus Group B (+0.19 logMAR). Graft failure or surgical complications were higher in Group B.
Conclusion: Prophylactic antiviral therapy significantly reduces the risk of HSV recurrence and improves surgical outcomes in patients with a prior ocular HSV history. In immunocompromised patients or cases of suspected acyclovir resistance, alternative antivirals such as valacyclovir or foscarnet may be considered.
Keywords
Antiviral prophylaxis
Acylcovir
Herpes simplex virus (HSV)
Ocular surgery
Postoperative complications
INTRODUCTION
Ocular herpes simplex virus (HSV) infections are a leading cause of infectious blindness globally.1,2 Patients with a history of HSV keratitis or uveitis are at increased risk for reactivation following ocular surgery due to surgical trauma and perioperative immunosuppression. Prophylactic antiviral therapy has been proposed to mitigate this risk,3 but clinical practice varies widely.
In day-to-day clinical practice, patients with healed or recurrent HSV commonly present for intraocular procedures such as cataract, corneal transplant, or glaucoma surgery. These cases require special consideration, especially in immunocompromised individuals, where viral reactivation may be more severe and less responsive to standard antiviral agents.
Particular attention should be given to cases involving acyclovir-resistant HSV, which are more frequently seen in immunocompromised patients. In such instances, alternative antiviral therapies, such as valacyclovir (which offers improved oral bioavailability) and foscarnet (especially for resistant strains), may be required.
This study compares post-surgical outcomes in patients who received prophylactic antiviral treatment and those who did not, providing evidence-based recommendations and addressing gaps in the current management approach, particularly in high-risk or resistant cases.
MATERIAL AND METHODS
Diagnosis of HSV infection
Diagnosis of previous ocular HSV infection was made based on one or more of the following:
Documented history of past HSV keratitis or uveitis by a qualified ophthalmologist
Prior use of antivirals (acyclovir/valacyclovir) with documented clinical improvement
Clinical signs suggestive of previous HSV infection, such as corneal scarring, ghost vessels, iris atrophy, or sectoral iris transillumination defects
History of recurrent unilateral ocular inflammation with resolution following antiviral therapy
In the absence of laboratory confirmation, diagnosis was established by experienced cornea or uveitis specialists using a combination of clinical history, examination findings, and therapeutic response.
Group allocation
Group A (n = 65): Received oral acyclovir (400 mg BID) preoperatively through 6 weeks post-op.
Group B (n = 60): Did not receive antiviral prophylaxis.
Outcome measures
Primary outcome: HSV recurrence within 12 months.
Secondary outcomes: Post-operative inflammation, graft rejection/failure, change in best-corrected visual acuity, and other complications.
Statistical Analysis
Data were analysed using SPSS v26. The chi-square test was used for categorical variables, and the t-test for continuous variables. Significance was defined as p < 0.05.
DISCUSSION
Surgical intervention in patients with a history of ocular HSV poses a considerable risk for viral reactivation [Figure 1].This study reinforces the clinical value of prophylactic antiviral therapy, with Group A showing significantly better outcomes across most parameters [Tables 1 and 2; Figure 2].2,4 The low recurrence rate and improved visual recovery in the prophylaxis group suggest that such treatment should be considered a standard of care.
- Herpetic dendrite on cornea.
| Outcomes | Prophylaxis group - Group A (n = 65) |
Non prophylaxis group - Group B (n = 60) | p-value |
|---|---|---|---|
| HSV recurrence, n(%) | 3 (4.6%) | 13 (21.7%) | <0.01 |
| Significant inflammation, n(%) | 4 (6.1%) | 14 (23.3%) | <0.01 |
| Graft failure (in graft cases), n(%) | 2 (3.1%) | 6 (10.0%) | 0.08 |
| Visual acuity improvement (logMAR), (mean+/-SD) | +0.31 ± 0.15 | +0.19 ± 0.17 | 0.02 |
| Other complications, n(%) | 1 (1.5%) | 5 (8.3%) | 0.05 |
SD: Standard deviation. p < 0.05 considered significant. HSV: Herpes simplex virus. logMAR: Logarithm of the minimum angle of resolution.
| Complication type | Prophylaxis group - Group A (n = 65), n(%) |
Non prophylaxis group - Group B (n = 60), n(%) |
|---|---|---|
| Elevated intraocular pressure | 1 (1.5%) | 2 (3.3%) |
| Secondary infection (non-HSV) | 0 | 1 (1.7%) |
| Persistent corneal edema | 0 | 1 (1.7%) |
| Delayed epithelial healing | 0 | 1 (1.7%) |
| Total | 1 (1.5%) | 5 (8.3%) |
Group A showed significantly lower HSV recurrence and postoperative inflammation, along with a greater improvement in visual acuity compared to Group B. HSV: Herpes simplex virus.
- Post-surgical complication rates in HSV history patients. HSV: Herpes simplex virus.
Notably, a few recurrences still occurred in the prophylaxis group, suggesting that higher dosages or longer duration may be needed for certain high-risk individuals.
This is especially important in immunocompromised patients, who may be more prone to reactivation or acyclovir resistance. In these situations, clinicians should consider transitioning to valacyclovir or foscarnet, which are effective against resistant HSV strains. Close postoperative monitoring is warranted in these populations, with low thresholds for treatment escalation.
While this study was limited to a single institution and used acyclovir alone for prophylaxis, the results strongly support the use of pre- and post-operative antiviral therapy in HSV-affected eyes.
CONCLUSION
In patients with a history of ocular HSV, prophylactic antiviral treatment significantly reduces the rate of HSV recurrence and inflammation and improves visual outcomes after ocular surgery. Special attention should be paid to immunocompromised patients and those with suspected antiviral resistance. Alternative agents, such as valacyclovir and foscarnet, should be considered in these settings. Ophthalmic surgeons should strongly consider integrating antiviral prophylaxis into the perioperative management of these high-risk patients.
Ethical approval:
The research/study approved by the Institutional Ethics Committee at Jamia Islamia Ishaatul Ulom’s Indian Institute of Medical Science and Research, with approval number JIMSR/IEC/PG/12/2022, dated 27th July 2022.
Declaration of patient consent:
Patient’s consent not required as patients identity is not disclosed or compromised.
Financial support and sponsorship:
Nil.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
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