Incidence And Clinical Patterns Of De Novo Herpetic Corneal Disease After Phacoemulsification

To describe new-onset of herpetic keratitis and/or endotheliitis after cataract surgery in patients without previous herpetic disease, and to report the incidence, related perioperative factors, clinical characteristics of this complication in a one-year surgical cohort, highlighting diagnostic challenges and implications for perioperative management.

Ophthalmology centre in Spain. Retrospective observational case series of patients that had treatment with oral antiviral therapy in the postoperative period of uneventful cataract surgery. We documented: prior herpetic disease, time before the appearance of keratitis, location of the lesion, layer of cornea of the lesion, location of the incision, accompanying diseases, perioperative medication and clinical presentation and manifestations

During 2025, 34 of 2,324 patients (1.46%) required oral antiviral therapy for presumed herpetic corneal disease after cataract  surgery. Seventeen patients with previous herpetic disease were excluded, leaving 17 patients  without prior herpetic history (0,73%).Corneal disease developed within 30 days postoperatively (mean onset 29 ± 5 days).Twelve eyes initially presented an epithelial defect adjacent to the corneal incision, progressing to typical dendritic keratitis within 2 to 3 days of onset. Six of these developed linear endotheliitis, with minimal anterior chamber reaction and low intraocular pressure. Five eyes presented primary horizontal linear endotheliitis with epithelial changes initially misdiagnosed as toxic keratopathy.

All patients received empirical  oral valaciclovir 500mg twice daily; topical steroids were added only in cases with endothelial involvement. Complete corneal healing and recovery of visual acuity occurred within one month. In combined epithelial and endothelial involvement, epithelial debridement shortened the clinical course.Despite antiviral prophylaxis, two patients developed epithelial keratitis after fellow-eye surgery. The association with the corneal incision suggests that surgical trauma to corneal nerves, together with postoperative topical steroids use, may contribute to viral reactivation. No correlation was found with systemic comorbidities or preoperative medication.

The prevalence of herpetic corneal diseases after cataract surgery was 0.7 % in patients without herpetic history. Three clinical patterns were identified: epithelial keratitis, horizontal linear endotheliitis and combined epithelial and endothelial involvement. Awareness of this entity is essential to avoid delayed diagnosis, as early epithelial changes may mimic toxic keratopathy. Close follow-up is mandatory and empirical oral antiviral therapy should be considered in cases of delayed epithelial recovery. Antiviral prophylaxis and minimum three-month interval before fellow-eye surgery may reduce recurrence risk.