Eye (1989) 3, 313-317 Ocular Surgery in Ophthalmic Zoster R. J. MARSH and M. COOPER London Summary Surgical outcome after ophthalmic zoster was analysed with respect to cataract, glaucoma, corneal ulceration and scarring. We used data from the Zoster Clinic and Hospital Activity Analysis (HAA) at Moorfields Eye Hospital and a lipid keratopathy database at the Western Ophthalmic Hospital. Conventional surgery for cataract, glaucoma and corneal scarring gave good results which were probably no different from experience with routine cases, although there was a tendency for prolonged post-operative inflammation. Lateral and central tarsorrhaphy for neuroparalytic ulceration almost invariably led to rapid healing. Many ophthalmologists are apprehensive glaucoma.6 Corneal scarring follows a small about operating on eyes that have been number of nummular, disciform and scle­ affected by herpes zoster ophthalmicus rokeratitis, sometimes forming a vascularised because they fear peroperative and post­ lipid keratopathy6 but otherwise complicates operative complications associated with neuroparalytic and exposure keratitis. Whilst inflammation. Therefore elective intraocular ulceration or glaucoma may need surgery surgery tends to be avoided. A survey of the whatever the underlying causes, cataract or literature is disappointing with only small corneal grafts tend to be avoided because the numbers of cases reported. 1,2,7 The com­ contralateral eye is usually normal. Our data monest complications requiring surgery are intended to help in evaluating the risks associ­ neuroparalytic ulcers, cataracts, glaucoma ated with such surgery. and corneal scars.1,2 Ulceration occurs in In view of the large number of cases of 6-8% of patients with neuroparalytic keratitis ophthalmic zoster seen at Moorfields Eye and in less than 3% with the chronic exposure Hospital we felt we had a unique opportunity type of keratitis. 3,4 Cataracts may precede, be to see if these fears for surgery were justified. aggravated or precipitated by zoster and often complicate chronic iritis with iris atrophy. Patients and Methods They can also be caused by long term use of Case-finding was done by reference to the potent topical steroids which may be neces­ Zoster Clinic, the Hospital Activity Analysis sary in the indolent ocular inflammationswith (HAA) at Moorfields, and the lipid kera­ zoster: They may be posterior subcapsular or topathy database at the Western Ophthalmic nuclear.5 Glaucoma, too, may precede zoster Hospital. The Zoster Clinic was started in but usually complicates disciform and mucous 1968 by Professor Barrie Jones. From 1973 plaque keratitis. Occasionally the picture is accurate prospective records were kept and in complicated by topical steroid-induced 1985 these and all new patients details were Correspondence to: R. J. Marsh, FRCS, Department of Clinical Ophthalmology, Moorfields Eye Hospital, City Road, London ECI 2PD. 314 R. J. MARSH AND M. COOPER added to a computer data base. Up to now Results 1700 patients have been seen and 1243 records Tarsorrhaphy: 45 patients were recorded on of those with regular follow-up computerised. the computer of which 40 had adequate follow The majority of primary and secondary refer­ up. Eleven of these were carried out early and rals to Moorfields Eye Hospital pass through 29 late. Neuroparalytic ulcers were respon­ the Zoster Clinic. The HAA, the main sible for ten in the former and twenty in the in-patient diagnostic data base for Moorfields, latter, the rest were due to a combination of was searched over the same period as the Zos­ exposure keratitis, partial loss of sensation and chronic oedema. Thirteen patients had ter Clinic for cataract surgery, glaucoma sur­ two or more procedures due to disintegration, gery and corneal grafting associated with premature opening and insufficiency of the zoster. The data base of 85 patients with lipid tarsorrhaphy (six of these were temporals keratopathy referred to the Western extended centrally). Accurate data on epi­ Ophthalmic Hospital, London for corneal thelial healing time was available in 29 cases of angiography was searched for those with zos­ which 13 recovered within a week, ten within ter who had been subsequently grafted. The one to two weeks and six were over two records were extracted and scrutinised with weeks. Reopening was successful in fiveof 12 relevant cases included in the series. cases. Tarsorrhaphies were temporal third as first Cataracts: (Table I) Eighteen patients had cat­ choice and classified as carried out either aract extractions of which eleven were extra­ within the firstthree months or subsequently. capsular with posterior chamber intraocular They were tabulated as follows:- the type of lenses (one was a triple procedure), two were corneal problem, early or late tarsorrhaphy, pure extracapsular and five intracapsular pro­ central or temporal, the number of these cedures. Accurate follow-up of more than one carried out or expanded on an individual case, year was available in 17 cases. Thirteen time for epithelial healing, late complications patients achieved 6/12 or better corrected and if reopening was successful. visual acuity, four did not because of pure Cataract cases were tabulated according to corneal scarring in two, macular degeneration age, date of zoster onset, acute complications, in one and a combination of both in one. whether they had prezoster cataract, type of Topical corticosteroids had to be increased operation, pre- and postoperative visual and continued for a prolonged period in three cases because of relapsing iritis. acuity, length of postoperative follow up and Glaucoma: (Table II) Twelve patients had finally a note on late complications. glaucoma surgery of which nine were tra­ Glaucoma cases were similarly tabulated beculectomies (one was a triple procedure), with the addition of whether there was prezos­ one was argon laser trabeculoplasty, and two ter glaucoma, the pre- and postoperative were peripheral iridectomies for complicating intraocular pressures, and whether the patient closed angle glaucoma (one occurring after a was on or off glaucoma medication delay of a year). Accurate follow up for at postoperatively. least a year was achieved in eleven cases. The Grafts were tabulated on a similar basis glaucoma was controlled in nine patients with­ with the addition of whether the cornea was out medical therapy and the remaining two vascularised preoperatively and if there had required hypotensive drops. The vision dete­ been argon laser therapy to the feeder vessels. riorated in seven patients because of cataract It was not possible to carry out reliable in six and a vitreous haemorrhage in one. The statistical comparisons. We had a relatively .latter occurred unaccountably two weeks small sample of cases and groups for com­ postoperatively and had not cleared one year parison were very heterogeneous and vir­ later. tually impossible to match. A search of the Corneal Grafts: (Table III) Nine patients had literature, too, yielded no satisfactory corneal grafts of which six were pure perfor­ comparable surgical results in otherwise ating keratoplasties, two combined with healthy eyes. extracapsular extraction with intraocular lens OCULAR SURGERY IN OPHTHAL MIC ZOSTER 315 Table I Cataract extractions Patient Zoster Pre Zoster Type of cataract Post op Post op initials Age complications cataract? operation va problems LW 35 disciform & iritis E/C + IOL 6/9 iritis IW R3 disciform & iritis E/C + IOL 6/36 macular degeneration RJ 41 iritis E/C + IOL 6/9 iris atrophy RW 75 iritis E/C + IOL 6/9 FM 63 iritis E/C + IOL 6/12 JC 54 disciform & iritis E/C + IOL 6/9 iritis CC 93 iritis Yes E/C + IOL 6/12 KL 56 disciform & iritis E/C + IOL 6/12 lipid keratopathy lA 66 iritis Yes E/C + IOL 6/6 GM 73 iritb Yes E/C + IOL 6/9 CW 45 disciform & iritis MPK Triple Proc 6/6 AA 64 neuroparalytic keratitis Yes E/C HM descemetocele RL 50 disciform & iritis MPK E/C 6/6 iritis HW R5 disciform & iritis IIC 6/18 macular degeneration TS 71 sclerokeratitis and iritis IIC 6/24 corneal scar LC 64 iritis IIC 6/9 corneal scar AB 65 neuroparalytic keratitis I/C 6/9 & iritis (equal distribution of sexes) MPK = Mucous plaque keratitis E/C = Extracapsular cataract extraction IIC = Intracapsular cataract extraction implantation and one was lamellar. Vessels achieved by tarsorrhaphy facilitated safer were closed preoperatively with the laser in topical steroid application for underlying iritis three cases. Accurate follow up for at least a and keratitis and the patient needed to be seen year was achieved in eight patients. Corrected less often. On reflection it may be better to visual acuities of 6/12 or bctter were achievcd intervene early because there seemed to be in seven patients. The one neuroparalytic less subsequent scarring and fewer outpatient ulcer had perforated and was grafted with a visits. However, our rate of tarsorrhaphies generous lateral third tarsorrhaphy per­ has been declining in the last two years and we formed at the same time. This functioned well felt that this was due to a more aggressive for four years but then decompensated prob­ policy of using Blenderm tape to temporarily ably due to the poor quality of the donor close the eye and to the use of Botulinu toxin corneal endothelium. A injection into the levator palpebrae to achieve a temporary complete ptosis.R Discussion There were fewer cataract operations than Bearing in mind the severity of the associated we anticipated and we had the impression that ocular disease these results were better than this was due to reticence to operate rather anticipated. Tarsorrhaphy led to rapid corneal than a lower incidence of cataract in zoster epithelial healing, the visual results in the cat­ patients. Perhaps, too, many were unilateral aract and graft patients were excellent and the cataracts and it appeared unnecessary to postoperative pressure control in the operate on most of them. Nevertheless intra­ glaucoma cases was also good.