Herpes Simplex Necrotizing Stromal Keratitis After Femtosecond Laser–Assisted Cataract Surgery With Arcuate Keratotomies: A Case Report

ABSTRACT: We report on a case of HSV-1 necrotizing stromal keratitis arising from femtosecond laser arcuate keratotomy wounds after femtosecond laser-assisted cataract surgery (FLACS) in a patient without known prior ocular herpes. An 80-year-old woman underwent uncomplicated FLACS with paired arcuate keratotomies and was discharged on topical dexamethasone and ofloxacin. Fifteen days later, examination showed dendritic lesions aligned with the keratotomy incisions, stromal infiltrates/necrosis, diffuse endotheliitis, and mild anterior uveitis. Oral valacyclovir and topical antiviral therapy were started with corticosteroids, but rapid progression occurred with hypopyon, worsening stromal necrosis, and hemorrhagic hyphema. Anterior chamber tap PCR confirmed HSV-1. Treatment escalated to fortified antibiotics during workup, intravitreal ganciclovir (with intravitreal antibiotics), anterior chamber washout, hospitalization for intravenous acyclovir, and later surgical management of secondary inflammation (pupillary membrane with iris bombé) with membrane removal and peripheral iridectomies. Inflammation gradually resolved and final best-corrected visual acuity improved to 0.4 logMAR. HSV reactivation may present as severe necrotizing stromal keratitis originating at femtosecond arcuate keratotomy sites even without a known herpetic history; early recognition and aggressive antiviral therapy with careful steroid use are crucial after FLACS.