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, , corneal ulceration and scarring. We used data from the Zoster Clinic and Hospital Activity Analysis (HAA) at Moorfields 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 for neuroparalytic ulceration almost invariably led to rapid healing.

Many ophthalmologists are apprehensive glaucoma.6 Corneal scarring follows a small about operating on 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 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 , 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. 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 , and two ter glaucoma, the pre- and postoperative were peripheral 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 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. Thus, apart ocular implantation seemed particularly suc­ from the need to increase topical steroids in a cessful, in our highly selected group. minority of patients for relapsing keratitis and Along with some relapsing keratitis and iritis the surgical procedures were straight­ iritis, cataract complicated a third of our tra­ forward. beculectomies. There was a definite reluc­ The rapid corneal epithelial healing tance to remove these which we felt was not 316 R. J. MARSH AND M. COOPER

Table II Glaucoma surgery

Post op On Patient Pre zoster Type of VIA glaucoma Post op initials Age Zoster complications glaucoma operation worse 6118 treatment? problems

RL 50 Disciform & MPK Yes Cataract JC 68 Disciform & MPK Yes Trabeculectomy Yes Cataract GK 57 Disciform & MPK Trabeculectomy MS 63 Iritis Trabeculectomy Yes Cataract FG 52 Disciform Yes Trabeculectomy CG 54 Iritis Yes Trabeculectomy Yes Cataract HB 77 Disciform Trabeculectomy Yes Vitreous Haemorrhage ML 62 Delayed closed angle Yes Laser PIs Yes Yes Cataract AF 73 Iritis and acute closed PIs angle AM 50 Disciform and scleritis ALT

PI = peripheral

ALT = argon laser trabeculoplasty

MPK = mucous plaque keratitis

Table III Corneal grafts

Patient Pre op Post op Follow up Post op initials Age Zoster complications laser Type of graft VIA in years problems

ID 56 Disciform and lipid Penetrating 6/9 9 Rejected keratopathy VB 60 Disciform and lipid Penetrating 6/9 9 keratopathy DJ 24 Disciform and lipid Penetrating 6/9 3 keratopathy IE 69 Disciform and lipid Yes Penetrating 6/12 5 Cataract keratopathy extracted JC 70 Sclerokeratitis & Yes Penetrating 6/9 5 lipid keratopathy EIC & lOL MS 73 Disciform and lipid Yes Penetrating 6/24 4 keratopathy EIC & lOL GA 76 Neuroparalytic Penetrating + 6/12 4 Endothelial keratitis tarsorrhaphgy decompensation NS 25 Disciform and lipid lamella 6/9 2 keratopathy

EIC = Extracapsular cataract extraction fully justified because safer techniques of with a stable epithelium and there was a good intraocular surgery are now available such as second eye. If any neuroparalytic or exposure extracapsular extraction and viscoelastic keratitis is to be grafted we would advise an substances. accompanying generous one third temporal We have to admit that all but one of our tarsorrhaphy. successful corneal grafts were in sensitive lipid In our experience properly indicated and scarred and those that were vas­ properly executed surgery in ophthalmic zos­ cularised had the vessels successfully closed ter does not seem to markedly prejudice the with argon laser preoperatively.9 The only surgical outcome or to alter the course of the neuroparalytic ulcer grafted was because of disease. Although based on small numbers of perforation. We felt that the main reasons operative cases we hope that these results will that no such cases were grafted electively was encourage others to undertake surgery more that tarsorrhaphy had achieved a quiet eye, readily in ophthalmic zoster patients. OCULAR SURGERY IN OPHTHALMIC ZOSTER 317

We would like to thank Mrs. B. Kendell for secretarial Zoster Ophthalmicus. Ophthalmology 1985, 92: assistance. 316-24. 5 Marsh RJ: Ophthalmic Herpes Zoster. In Darrell RW. Viral diseases of the Eye. Philadelphia: Lea and Febiger1985, 78-89. References 6 Marsh RJ: Ophthalmic Herpes Zoster. Br J Hasp 1 Womack LW and Liesegang TJ: Complications of Med 1976, 609-18. Herpes Zoster Ophthalmicus. Arch Ophthalmol 7 Edgerton AE: Herpes Zoster Ophthalmicus Report 1983, 101: 42-5. of cases and review of the literature. Arch 2 Marsh RJ and Cooper M: Ophthalmic Zoster Ophthalmol1945, 34: 40-62, 114-53. mucous plaque keratitis. Br J Ophthalmol 1987, 8 Adams GGW, Kirkness CM, Lee JP: Botulinum 71: 725-8. Toxin A induced protective ptosis. Eye 1987, 1: 3 Marsh RJ: Herpes Zoster Keratitis. Trans 603-8. Ophthalmol Soc UK1973, 93: 181-90. 9 Marsh RJ and Marshall RJ: The treatment of lipid 4 Liesegang TJ: Corneal Complications from Herpes keratopathy.Br J Ophthalmol1982, 66: 127-35.