1

ARTICLE

High rate of recurrence of herpes

zoster–related ocular disease after
phacoemulsification cataract surgery
Lucy M. Lu, MB ChB, PGDipOphth BS, Charles N.J. McGhee, MB ChB, PhD, DSc, FRCOphth,
Joanne L. Sims, MB ChB, FRANZCO, Rachael L. Niederer, MB ChB, PhD, FRANZCO

Purpose: To examine the outcomes of phacoemulsification cata-
ract surgery in eyes with herpes zoster-related keratitis and/or
uveitis and evaluate the risks for recurrent disease.
Setting: Public ophthalmology service, Auckland, New Zealand.
Design: Retrospective case series.
Methods: Patients with herpes zoster–related keratitis and/or
uveitis who had cataract surgery in the ipsilateral eye were
reviewed. Outcome measures were intraoperative and
postoperative complications, postoperative visual acuity, and
recurrent disease.
Results: Fifty-seven eyes of 57 patients were included. Thirty-
eight patients (66.7%) had recurrent disease before cataract
surgery. Intraoperative complications occurred in 8 patients
(14.0%) and included posterior capsule tear in 2 patients (3.5%).
Postoperative complications included intraocular pressure of
30 mm Hg or higher in 2 patients (3.5%) and central corneal
edema in 8 patients (14.0%); all resolved by 1 month. Cystoid
macular edema occurred in 2 patients (3.5%). The median
corrected distance visual acuity at 12 months was 20/40
(interquartile range, 20/30-20/50). Corneal scarring was
associated with poorer vision (P Z .003). Herpes zoster recurred
in 23 patients (40.4%) after surgery. An increased risk for
recurrence was associated with shorter periods of quiescence
(P Z .029) and greater number of recurrences before surgery
(P Z .039). One eye was eviscerated because of the severity of
the disease.
Conclusions: Phacoemulsification in eyes with previous herpes
zoster–related keratitis or uveitis posed a mildly increased risk for
intraoperative and postoperative complications; however, herpes
zoster disease recurrence after surgery was common and was
severe in some cases. Consideration should be given to
maximizing the period of quiescence before surgery and the
potential role of antiviral prophylaxis.
J Cataract Refract Surg 2019; -:-–- Q 2019 ASCRS and ESCRS

H
erpes zoster ophthalmicus (HZO) is reactivation
of the varicella zoster virus (VZV) affecting the
ophthalmic division of the trigeminal nerve. It
has been estimated that 1 in 3 people will develop herpes
zoster in their lifetime, with HZO accounting for 10% to
20% of cases.1 Advancing age and immunosuppression in-
crease the risk for herpes zoster.2 Ocular involvement has
been reported in 30% to 78% of HZO cases and can man-
ifest as inflammation of all anatomic structures of the eye,
most commonly conjunctivitis, keratitis, uveitis, and trabe-
culitis causing increased intraocular pressure (IOP).3 Her-
pes zoster ophthalmicus can lead to chronic and recurrent
ocular inflammation and secondary glaucoma and result
in significant visual morbidity.3 The recurrence rate of
HZO-related keratitis and uveitis has been reported to
be 25% at 5 years.4 This means potentially prolonged corti-
costeroid use and an increased risk for long-term
complications.
Cataract formation is common in patients affected by
HZO because of a combination of risk factors, including
older age, ocular inflammation, and corticosteroid use.
Cataract surgery in eyes with a history of uveitis is more
complex, with an increased incidence of intraoperative
and postoperative complications.5 However, little is known
about the outcomes of cataract surgery in patients with her-
pes zoster keratitis or uveitis. A study by He et al.6 examined
the outcomes of cataract surgery in 24 patients with a his-
tory of HZO. The authors observed a recurrence of ocular

Submitted: August 20, 2018 | Final revision submitted: December 28, 2018 | Accepted: January 2, 2019
From the Departments of Ophthalmology, New Zealand National Eye Centre (Lu, McGhee), University of Auckland, and Greenlane Clinical Centre (Lu, McGhee, Sims,
Niederer), Auckland District Health Board, New Zealand.
Corresponding author: Lucy M. Lu, MB ChB, PGDipOphthBS, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand. Email: lucymmlu@
gmail.com.

Q 2019 ASCRS and ESCRS 0886-3350/$ - see frontmatter

Published by Elsevier Inc. https://doi.org/10.1016/j.jcrs.2019.01.003
2 RECURRENCE OF HERPES ZOSTER AFTER CATARACT SURGERY
disease in 25% of patients after surgery and high rates of
complications, including persistent epithelial defect
(25.0%), corneal neovascularization (21.8%), and cystoid
macular edema (CME) (8.3%).6
The current study explored the clinical course and out-
comes of cataract surgery in eyes with HZO-related keratitis
and uveitis and the risk for recurrence after cataract
surgery.
PATIENTS AND METHODS
This retrospective review was performed at a major tertiary
ophthalmology department in New Zealand. The goal was to iden-
tify all patients diagnosed with HZO-related keratitis and uveitis
attending between January 1, 2005, and December 31, 2015,
who subsequently had cataract surgery in the affected eye. This
study was approved by the Research Development Office, Auck-
land District Health Board (AC 7938), and complied with the te-
nets of the Declaration of Helsinki.
Patients were identified from a departmental uveitis database
and by searching for a diagnosis of HZO on all eye clinic discharge
summaries (using International Classification of Diseases 10 codes
and free text searches). The operating room surgery code for
phacoemulsification and intraocular lens (IOL) implantation
was used to identify all patients who also had cataract surgery.
The clinical notes for these patients were reviewed, and patients
were included if they had clinical presentation of HZO with kera-
titis or anterior uveitis or if they had anterior uveitis consistent
with a viral picture that was confirmed to be VZV on aqueous hu-
mor tap. Patients with acute retinal necrosis or panuveitis second-
ary to VZV were excluded because they had a poorer prognosis
and a different subset of complications.
Data collected included patient demographics, age at initial pre-
sentation of HZO, subsequent ocular disease, number of recur-
rences or flares of HZO keratitis and/or uveitis before and after
cataract surgery, intraoperative complications, and follow-up
findings 1 month, 3 months, and 12 months after cataract surgery.
A recurrence was defined as the reappearance of herpes zoster–
related keratitis or uveitis after it was noted to be quiescent at
the last appointment. A flare of uveitis was defined as worsening
of anterior chamber inflammation by 1C cells or requiring an in-
crease in topical or systemic steroid therapy. The corrected dis-
tance visual acuity (CDVA) was recorded in Snellen form and
converted to logarithm of the minimum angle of resolution nota-
tion for data analysis.7 All diagnoses of CME were confirmed by an
optical coherence tomography (OCT) scan. Patients had OCT
examination of the macula if the CDVA was 20/30 or worse at
the 1-month postoperative visit, if there was a subsequent decline
in CDVA not explained by corneal pathology, or if there was a
clinical suspicion of CME.
Data analysis was performed using SPSS statistical software
(version 25, IBM Corp.). Continuous data are presented as median
(interquartile range [IQR]) for skewed data. Categorical data are
presented as number (percentage). The independent t test,
Mann-Whitney U test, or chi-square test was used to compare
patient-related observations. Kaplan-Meier estimation and Cox
regression analysis were used to examine the time to recurrence
of herpes zoster after cataract surgery. All tests were 2-tailed,
and a P value less than 0.05 was considered statistically significant.
RESULTS
Demographics
Of the 983 patients identified as having HZO, 62 (6.3%) had
subsequent cataract surgery. Five patients were excluded
because there was no evidence of keratitis or uveitis, leaving
57 eyes of 57 patients in the study. The median age at time
of HZO diagnosis was 71.4 years (IQR, 65.9-76.8 years),
Volume - Issue - - 2019
and 34 patients (59.6%) were men. Self-identified ethnicity
was predominantly white (n Z 45 [78.9%]) followed by
Chinese (n Z 5 [8.8%]), Pacific Island national (n Z 3
[5.3%]), Maori (n Z 2 [3.5%]), and other (n Z 2 [3.5%]).
Nine patients were immunosuppressed at time of presenta-
tion, including 2 patients with Crohn disease, 1 with rheu-
matoid arthritis, 2 with chronic lymphocytic leukemia, 2 on
low-dose prednisone for polymyalgia rheumatica, and 2
with a solid organ transplant. No patients were human im-
munodeficiency virus positive.
Presenting Disease
At presentation, 55 (96.5%) patients had a typical clinical
presentation of HZO, with unilateral rash in the ophthalmic
distribution. Antiviral use was documented in 54 patients,
of whom 48 (88.9%) received 7 to 10 days of oral antiviral
therapy. The course of antiviral was started within 3 days
of onset of the rash in 38 patients (66.7%). Two patients
had recurrent uveitis typical of a viral picture and were sub-
sequently diagnosed on aqueous humor polymerase chain
reaction; 1 patient with clinical HZO also had a positive
aqueous tap at the time of cataract surgery. The median
CDVA at presentation was 20/30 (IQR, 20/25-20/60), and
the median IOP was 17 mm Hg (IQR, 12-24). Fourteen pa-
tients (24.6%) presented with an IOP of 24 mm Hg or high-
er, and 7 patients (12.3%) presented with an IOP greater
than 30 mm Hg. Corneal disease was present in 37 patients
(64.9%) at presentation, with pseudodendrites in 21
(36.8%) and disciform keratitis in 19 (33.3%). Forty-eight
patients (84.2%) had anterior uveitis at presentation.
Preoperative Cataract Assessment
The median time to cataract surgery was 2.8 years (IQR,
1.6-4.5 years). Thirty-eight patients (66.7%) had recurrent
disease before cataract surgery, with 28 (49.1%) having
recurrent corneal disease and 25 (43.9%) having recurrent
uveitis. The median number of recurrences before cataract
surgery was 2 (IQR, 0-4). The median time from last flare to
cataract surgery was 1.2 years (IQR, 0.7-2.4 years). Twenty-
two patients (38.6%) had surgery less than 1 year after the
last flare of disease, and 3 patients (5.3%) had surgery fewer
than 3 months after the last flare. Raised IOP was common
during the course of the disease, with 27 patients (47.4%)
having an IOP greater than 24 mm Hg before surgery
and 19 (33.3%) with IOP greater than 30 mm Hg. Eleven
patients (19.3%) required treatment for ocular hyperten-
sion (IOP O24 mm Hg persisting for more than 1 month
after control of inflammation), and 7 patients (12.3%)
developed glaucomatous optic neuropathy.
At the preoperative assessment, the median visual acuity
was 20/100 (IQR, 20/50-20/400). Twenty-five patients
(43.9%) had a central corneal scar, 6 patients (10.5%) had
iris transillumination defects, 5 patients (8.8%) had poste-
rior synechiae, and 3 patients (5.3%) had peripheral ante-
rior synechiae. Thirty-two patients (56.1%) received a
prophylactic topical corticosteroid before cataract surgery.
This included 28 patients who were receiving long-term
topical steroid to decrease the rate of recurrence of HZO,
 RECURRENCE OF HERPES ZOSTER AFTER CATARACT SURGERY
and 4 patients who were started on topical corticosteroid 3
to 7 days before cataract surgery. For those on long-term
topical corticosteroid before cataract surgery, the median
duration was 15.5 months (IQR, 4.0-21.75). Two patients
(3.5%) received oral prednisone (40 mg) before surgery.
No patient was on a long-term prophylactic oral antiviral
agent; however, 6 patients (including the 2 who received
oral prednisone) were started on acyclovir 400 mg twice
daily for 1 week before surgery.
Cataract Surgery
Trypan blue was used to stain the anterior capsule in 14 pa-
tients (24.6%), including 9 patients with a central corneal
scar and 5 patients with dense cataract and inadequate red
reflex. Three patients required iris hooks for management
of poor pupil dilation, 1 had a placement of a pupillary
expansion ring (Malyugin ring), and 2 had pupil stretching.
Intraoperative Complications
Intraoperative complications occurred in 8 patients (14.0%)
and included anterior capsule tear in 3 patients (5.3%), pos-
terior capsule tear in 2 patients (3.5%), iris prolapse in 2 pa-
tients (3.5%), and zonular fiber weakness requiring a
capsular tension ring in 1 patient (1.8%). One patient
with a posterior capsule tear required anterior vitrectomy
with a sulcus-fixated IOL. In the other case, there was no
vitreous loss and an IOL was placed in the capsular bag.
There were no instances of dropped nucleus or lens frag-
ment. No difference in the risk for complicated surgery
was observed by age, sex, or ethnicity. Corneal disease at
presentation or subsequently was not associated with
increased risk; however, an increased risk for complications
was observed in patients with chronic anterior uveitis
compared with patients without chronic anterior uveitis
(3 patients [37.5%] versus 5 patients [11.4%]; P Z .039)
and in patients with glaucomatous optic neuropathy (3 pa-
tients [42.9%] versus 5 patients [10.0%]; P Z .019). There
was a trend toward an increased complication rate in pa-
tients with a history of raised IOP over 24 mm Hg (6 pa-
tients [22.2%] versus 2 patients [6.7%]; P Z .091),
although this did not reach statistical significance. Acute
anterior uveitis at presentation or subsequently was not
associated with an increased risk for complicated surgery.
The presence of a corneal scar, iris transillumination, pos-
terior synechiae, or peripheral anterior synechiae before
cataract surgery was also not associated with a risk for com-
plications, nor was the preoperative visual acuity.
Postoperative Complications
Table 1 shows the CDVA and presence of inflammation af-
ter surgery. A 12-month follow-up was available for 40 pa-
tients (70.2%). At the 12-month follow-up, 9 patients
(22.5%) had a CDVA worse than 20/50 and 3 patients
(7.5%) had a CDVA worse than 20/200. A poor visual
outcome was more prevalent in patients with a central
corneal scar at the preoperative assessment (P Z .003).
Complicated cataract surgery did not correlate with poor
visual acuity; no patient with complicated surgery had a
3
12-month CDVA of 20/50 or worse. Seven patients
(12.3%) had a decline in the 12-month CDVA compared
with the CDVA preoperatively. Patients were followed for
a median of 5.6 years (IQR, 3.6-8.0). Visual acuity at the
last follow-up appointment was 20/40 (IQR, 20/30-20/100).
At the 1-day follow-up, the IOL was greater than 24 mm
Hg in 8 patients (14.0%) and greater than 30 mm Hg in 2
patients (3.5%). At the 1-month follow-up, only 1 patient
had an IOP greater than 24 mm Hg, and none had an
IOP greater than 30 mm Hg. Central corneal edema with
Descemet membrane folds was noted in 8 patients
(14.0%) at the 1-day; it resolved in all patients by the
1-month follow-up. However, 1 patient had a clear cornea
at the initial follow-up but subsequently developed recur-
rent anterior uveitis after uneventful cataract surgery
(although requiring trypan blue and iris hooks) and subse-
quently developed corneal decompensation, having pene-
trating keratoplasty 14 months following cataract surgery.
Inflammation was still present at the 1-month follow-up
in 8 patients (14.0%), requiring a longer corticosteroid ta-
per. Two patients (3.5%) developed CME, which was
observed at the 1-month appointment in 1 patient and at
3 months in the other patents. Both cases resolved with
topical treatment only. One patient presented 5 months
postoperatively with a recurrence of anterior uveitis and
dislocation of the IOL and required a vitrectomy, removal
of the IOL, and sulcus-fixated IOL implantation. No patient
required another surgery within the first 3 months
postoperatively.
Recurrence Herpes Zoster Ophthalmicus After Surgery
The HZO recurred in 23 patients (40.4%) after cataract sur-
gery and was most common in the first 2 years (Figure 1).
Three patients developed band keratopathy from repeated
inflammation, and 1 patient developed neurotrophic kera-
titis with a persistent epithelial defect. One eye in a patient
with Crohn disease, which was being treated with azathio-
prine and prednisone, had a severe recurrence of keratitis
with corneal melt and required evisceration 8 months after
cataract surgery. Table 2 shows the risk factors for recur-
rence of herpes zoster keratitis or uveitis after surgery. On
univariate analysis, recurrent disease before cataract sur-
gery, number of recurrences after cataract surgery, time
from last flare of active inflammation, and topical steroid
or oral acyclovir as preoperative prophylaxis were associ-
ated with a risk for recurrence of disease after cataract sur-
gery. On multivariate analysis, the number of recurrences
before surgery and time from last flare of inflammation
were significantly associated with a risk for recurrent dis-
ease. In patients with more than 1 year of disease quiescence
before cataract surgery, the risk for recurrence was signifi-
cantly lower (9 patients [25.7%] versus 14 patients
[63.6%]; P Z .004).
DISCUSSION
We believe this is the largest study to date examining the
outcomes of cataract surgery in eyes with a history of herpes
zoster keratitis and uveitis. Cataract surgery in this
Volume - Issue - - 2019
4 RECURRENCE OF HERPES ZOSTER AFTER CATARACT SURGERY

Table 1. Clinical outcomes after cataract surgery.

Corrected Distance
Visual Acuity
Presence of
Postop Exam Median IQR AC Cells (%)
1 day 20/40 20/30, 20/50 80.7
1 month 20/40 20/30, 20/60 14.0
3 months 20/30 20/25, 20/50 10.6
12 months 20/40 20/30, 20/50 5.1

AC Z anterior chamber; IQR Z interquartile range

Figure 1. Kaplan-Meier estimation of the time to recurrence of her-

population is potentially complex; however, the rate of in-
traoperative complications was only mildly elevated.
Table 3 shows the reported adverse events compared with
the those in the Auckland Cataract Studies (ASC), which
audited consecutive phacoemulsification surgeries per-
formed at the same institution.8,9 Anterior capsule tear
and pupil manipulation were more common; however,
the rates of posterior capsule tear, iris prolapse, and drop-
ped nucleus were similar to those for routine cataract sur-
geries performed at our center.8,9 Cataract surgery in
uveitic eyes is more complex and challenging, with
increased intraoperative and postoperative complications5;
however, most previous studies were based on noninfective
uveitis and there is a paucity of literature on cataract sur-
gery in herpetic disease.6 Notably, patients with a history
of chronic anterior uveitis or glaucomatous optic neuropa-
thy were more likely to have intraoperative complications,
although no increased risk was observed with signs on pre-
operative examination, including central corneal scar, pos-
terior synechiae, and iris transillumination. However,
glaucomatous optic neuropathy might be a marker of the
severity or duration of previous inflammation rather than
having a causative association, per se.
Despite 43.9% of patients having preexisting herpes
zoster–related corneal scarring, the postoperative visual
acuity outcomes were reasonable, with 77.5% of patients
achieving a CDVA of 20/40 or better (driver’s license stan-
dard in New Zealand). In comparison, the ACS 29 reported
that 88% of patients achieved a CDVA of better than 20/40.
In a meta-analysis of uveitic cataract surgery by Mehta
et al.,10 68% achieved a CDVA of better than 20/40 after
phacoemulsification. Therefore, visual acuity outcomes in
pes zoster keratitis and uveitis following cataract surgery (57 pa-
tients; median postoperative follow-up 5.6 years).
the current study are better than reported outcomes in uve-
itis but not as good as those after routine cataract surgery at
our institution.
Perhaps surprisingly, the rate of postoperative CME
(3.5%) compares well with that of routine cataract surgery
performed at our center (3.8% and 3.5% in ACS 18 and
ACS 2,9 respectively) and is lower than previously reported
after cataract surgery in HZO (8.3%, He et al.6) and in pa-
tients with a history of anterior uveitis (12.7%, Kosker
et al.11)
We observed a high rate of recurrence of HZO disease
(40.4%) after cataract surgery, most commonly in the first
2 years. In 3 patients, the complications from the recurrence
were severe; 1 developed corneal decompensation after se-
vere uveitis requiring penetrating keratoplasty, 1 developed
recurrent uveitis with dislocation of the IOL, and the third
developed corneal melt refractory to conservative treat-
ment, requiring evisceration of the eye. The risk for postop-
erative recurrence increased with the number of flares
before surgery and decreased with duration of quiescent
disease before surgery.
Six patients (10.5%) received prophylactic oral acyclovir
preoperatively. Although the role of acyclovir in acute pri-
mary HZO is well established, there is little published liter-
ature on its role in treating or preventing chronic or
recurrent HZO.12,13 The mainstay treatment for HZO ker-
atouveitis is a corticosteroid (usually topical). The use of
systemic antiviral therapy is highly variable between clini-
cians and centers.14 We observed that acyclovir prophylaxis

Table 2. Risk for recurrent herpes zoster keratitis or uveitis after cataract surgery.
Univariate Analysis Multivariate Analysis

Variable P Value HR P Value HR

Recurrent disease before surgery .024 2.045 .353 0.444
Number of recurrences prior to surgery !.0005 1.467 .029 1.338
Time from diagnosis .150 0.856 d d
Time from last flare .008 0.335 .039 0.371
Topical steroid preoperatively .007 0.435 .139 0.591
Oral acyclovir preoperatively .072 0.627 .568 1.187
Complicated cataract surgery .727 0.908 d d

HR Z hazard ratio

Volume - Issue - - 2019

 RECURRENCE OF HERPES ZOSTER AFTER CATARACT SURGERY
Table 3. Cataract surgery adverse events in the current
study compared with Auckland Cataract Studies.
Percentage
Current
Adverse Event Study ACS18 ACS29
Anterior capsule tear 5.3 2.2 1.2
Posterior capsule tear 3.5 4.9 2.2
Iris prolapse 3.5 4.3* 2.6
Manipulation of small pupil 8.8 2.9 NR
Dropped nucleus fragment 0.0 0.8 0.2
1 day postop IOP O30 mm Hg 3.5 4.3 NR
Cystoid macular edema 3.5 3.8 3.5
Endophthalmitis 0.0 0.2 0.0
ACS Z Auckland Cataract Studies; IOP Z intraocular pressure; NR Z not
reported
*Including iris trauma
protected against the recurrence of HZO after cataract sur-
gery on univariate analysis but not on multivariate analysis.
There was also significant bias within the group because
those commenced on prophylactic treatment were more
likely to have significant recurrent disease. The Zoster Eye
Disease Study to address this paucity of evidence in HZO
is currently in progress. The trial will compare 1 year of sup-
pressive oral valacyclovir (1 g daily) to a placebo and the ef-
fect on the rates of new or worsening anterior segment
ocular disease during and after treatment.15 This will help
guide the management of HZO ocular disease. Future
studies evaluating the potential benefit of antiviral prophy-
laxis before and after ocular surgery are also warranted.
The incidence of herpes zoster is increasing across the
globe.16 With an aging population in countries such as
the United States, United Kingdom, and New Zealand,
the number of patients with HZO requiring cataract sur-
gery will likely increase. However, with the introduction
of vaccines against herpes zoster, we might see a decrease
of herpes zoster incidence in the future. At present, 2 vac-
cines for the prevention of herpes zoster are available in
the U.S. Shingrix,A a recombinant vaccine recommended
for healthy adults aged 50 years or older, was approved in
2017, and is now the preferred vaccine over the older vac-
cine Zostavax,B a live vaccine in use since 2006. In New Zea-
land, Zostavax was approved for funding in April 2018 and
is available to all residents aged 65 years or older. Although
a history of HZO with ocular involvement is not a contra-
indication to vaccination, there is still uncertainty regarding
how long to wait after HZO before vaccinating.17 A few
cases of reactivation of HZO keratouveitis occurring
approximately 2 to 5 weeks after Zostavax administration
have been reported, including 1 case that resulted in a
corneal perforation.18–21 It is important to inform patients
and their general physicians about the potential risk for re-
activation and arrange close follow-up in the weeks after the
patient receives the vaccination.
Herpes zoster ophthalmicus is a common condition
encountered by every ophthalmologist. Although our
study shows that cataract surgery in patients with HZO
5
can be complex, intraoperative complications were only
mildly increased and postoperative complications directly
related to surgery were equivalent to those in routine cata-
ract surgery. Our primary concern was the high rate of se-
vere sequelae from herpes zoster disease recurrence after
surgery. Thus, we recommend careful patient selection,
detailed informed consent, a long period of disease quies-
cence before cataract surgery (minimum 6 months; ideally
1 year), and consideration of oral antiviral therapy in
those with a history of multiple disease recurrences. Re-
view of the contemporary literature highlights significant
gaps in our current knowledge, and future prospective
randomized controlled trials will hopefully shed more
light.
WHAT WAS KNOWN
 Herpes zoster ophthalmicus (HZO) is common in the older
population and can result in chronic and recurrent inflam-
mation of ocular structures, in particular anterior segment
inflammation.
 People with previous HZO keratitis or uveitis are more likely
to develop cataract because of their age, exposure to
inflammation, and topical steroid use; they are predisposed
to surgical complications and the risk for recurrent
inflammation.
WHAT THIS PAPER ADDS
 Cataract surgery in eyes with a history of HZO anterior
segment inflammation was associated with moderate rates
of intraoperative and postoperative complications; however,
the majority of patients achieved a corrected distance visual
acuity of 20/40 or better. Preoperative corneal scarring was
a major limitation to a good visual outcome.
 Recurrence of herpes zoster-related keratitis and uveitis was
frequent (40.4%) and was more common with shorter pe-
riods of quiescence and greater number of recurrences
before surgery. In a few cases, disease recurrence led to
severe sequelae.
REFERENCES
1. Ragozzino MW, Melton LJ, Melton LJ III, Kurland LT, Chu CP, Perry HO.
Population-based study of herpes zoster and its sequelae. Medicine
1982; 61:310–316
2. Harding SP, Lipton JR, Wells JC. Natural history of herpes zoster ophthal-
micus: predictors of postherpetic neuralgia and ocular involvement. Br J
Ophthalmol 1987; 71:353–358
3. Liesegang TJ. Herpes zoster ophthalmicus; natural history, risk factors,
clinical presentation, and morbidity. Ophthalmology 2008; 115 (suppl
2):S3–S12
4. Tran KD, Falcone MM, Choi DS, Goldhardt R, Karp CL, Davis JL, Galor A.
Epidemiology of herpes zoster ophthalmicus; recurrence and chronicity.
Ophthalmology 2016; 123:1469–1475
5. Agrawal R, Murthy S, Ganesh SK, Phaik CS, Sangwan V, Biswas J. Cata-
ract surgery in uveitis. Int J Inflam 2012; 2012; article ID:548453
6. He Y, de Melo Franco R, Kron-Gray MM, Musch DC, Soong HK. Outcomes
of cataract surgery in eyes with previous herpes zoster ophthalmicus.
J Cataract Refract Surg 2015; 41:771–777
7. Lange C, Feltgen N, Junker B, Schulze-Bonsel K, Bach M. Resolving the
clinical acuity categories “hand motion” and “counting fingers” using the
Freiburg Visual Acuity Test (FrACT). Graefes Arch Clin Exp Ophthalmol
2009; 247:137–142
8. Riley AF, Malik TY, Grupcheva CN, Fisk MJ, Craig JP, McGhee CN.
The Auckland Cataract Study: co-morbidity, surgical techniques, and
Volume - Issue - - 2019
6 RECURRENCE OF HERPES ZOSTER AFTER CATARACT SURGERY

clinical outcomes in a public hospital service. Br J Ophthalmol 2002;
86:185–190
9. Kim BZ, Patel DV, McGhee CNJ. Auckland Cataract Study 2: clinical out-
comes of phacoemulsification cataract surgery in a public teaching hospital.
Clin Exp Ophthalmol 2017; 45:584–591
10. Mehta S, Linton MM, Kempen JH. Outcomes of cataract surgery in patients
with uveitis: a systematic review and meta-analysis. Am J Ophthalmol 2014;
158:676–692.e7
11. Kosker M, Sungur G, Celik T, Unlu N, Simsek S. Phacoemulsification with
intraocular lens implantation in patients with anterior uveitis. J Cataract
Refract Surg 2013; 39:1002–1007
12. Cobo LM, Foulks GN, Liesegang T, Lass J, Sutphin JE, Wilhelmus K,
Jones DB, Chapman S, Segreti AC, King DH. Oral acyclovir in the
treatment of acute herpes zoster ophthalmicus. Ophthalmology 1986;
93:763–770
13. Harding SP. [Letter to the editor]. Eye 1995; 9:390–391; reply by Alyward
GW, Marsh RJ, Claou e CMP, 391–392
14. Sy A, McLeod SD, Cohen EJ, Margolis TP, Mannis MJ, Lietman TM,
Acharya NR. Practice patterns and opinions in the management of recur-
rent or chronic herpes zoster ophthalmicus. Cornea 2012; 31:786–790
15. Cohen EJ, Kessler J. Persistent dilemmas in zoster eye disease. Br J Oph-
thalmol 2016; 100:56–61
16. Kawai K, Gebremeskel BG, Acosta CJ. Systematic review of incidence and
complications of herpes zoster: towards a global perspective. BMJ Open
2014; 4 (6):e004833
17. Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster.
Recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep 2008; 57:1–30
18. Hwang CW Jr, Steigleman WA, Saucedo-Sanchez E, Tuli SS. Reactivation
of herpes zoster keratitis in an adult after varicella zoster vaccination.
Cornea 2013; 32:508–509
19. Jastrzebski A, Brownstein S, Ziai S, Saleh S, Lam K, Jackson WB. Reacti-
vation of herpes zoster keratitis with corneal perforation after zoster vacci-
nation. Cornea 2017; 36:740–742
20. Khalifa YM, Jacoby RM, Margolis TP. Exacerbation of zoster interstitial kera-
titis after zoster vaccination in an adult [letter]. Arch Ophthalmol 2010;
128:1079–1080
21. Sham CW, Levinson RD. Uveitis exacerbation after varicella-zoster vaccina-
tion in an adult [letter]. Arch Ophthalmol 2012; 130:793–794
OTHER CITED MATERIAL
A. GSK. Shingrix zoster vaccine; recombinant adjuvanted. Available at: https:
//gsksource.com/pharma/content/gsk/source/us/en/brands/shingrix/pi/ho
me.html. Accessed February 3, 2019
B. Merck Sharp & Dohme Corp. Zostavax. Available at: https://www
.merckvaccines.com/Products/Zostavax. Accessed February 3, 2019
Disclosures: None of the authors has a financial or proprietary in-
terest in any material or method mentioned.
First author:
Lucy M. Lu, MB ChB, PGDipOphth BS
Department of Ophthalmology, New
Zealand National Eye Centre, University of
Auckland, New Zealand

Volume - Issue - - 2019