Human Immunodeficiency Virus Infection

Little has been written about refractive surgery in patients with known human immunodeficiency virus (HIV) infection, and individual opinions vary. Note that the FDA recommends that patients with an immunodeficiency disease not undergo LASIK, regardless of the excimer platform, because the risk outweighs the benefit.

In a survey of members of the International Society of Refractive Surgery, 51% of respondents considered HIV-seropositive patients who did not have definite acquired immune deficiency syndrome (AIDS) to be acceptable refractive surgery candidates. Only 13% thought that patients with definite AIDS were candidates for refractive surgery, whereas 44% believed that the presence of AIDS was an absolute contraindication to refractive surgery. Some surgeons advise such patients against undergoing refractive surgery because of concerns about postoperative complications, including the increased risk of infection associated with immunosuppression. However, only 1 case of keratitis (a bilateral infection with Staphylococcus aureus) following LASIK in an HIV-seropositive patient has been reported.

An additional concern is the potential for aerosolizing live virus during laser ablation, which could pose a risk to laser-suite personnel. Because refractive surgeons may operate on patients who do not know they are infected with viruses such as HIV or one of the hepatitis viruses, universal precautions must be followed with all patients.

In 1 study, excimer laser ablation of a cornea infected with pseudorabies virus, a porcine-enveloped herpesvirus similar to HIV and HSV, did not appear capable of causing infection by transmission through the air. The authors concluded that excimer laser ablation of the cornea in a patient infected with HIV is unlikely to pose a health hazard to the surgeon or assistants. Another study demonstrated that, after excimer laser ablation of infected corneal stroma, polymerase chain reaction did not detect viable varicella virus (200 nm in diameter) but did detect viable polio particles (70 nm in diameter).

Inhaled particles greater than or equal to 5 μm in diameter are deposited in the bronchial, tracheal, nasopharyngeal, and nasal walls, and particles less than 2 μm in diameter are deposited in the bronchioles and alveoli. Even if viral particles are not viable, the excimer laser plume produces particles with a mean diameter of 0.22 μm. Although the health effects of inhaled particles from the plume have not yet been determined, there have been anecdotal reports of respiratory ailments such as chronic bronchitis in high-volume excimer laser refractive surgeons. Canister filter masks can exclude particles down to a diameter of 0.1 μm and may be more protective than conventional surgical masks. In addition, evacuation of the laser plume potentially decreases the amount of breathable debris.

If a surgeon is considering performing excimer laser ablation in an HIV-infected patient who is not immunocompromised and has normal results on eye examination, extra precautions are warranted. The surgeon should counsel the patient about the visual risks of HIV infection and the lack of long-term follow-up results for refractive surgery in this population. The surgeon may also consider consulting with the physicians managing the patient’s underlying disease, including specialists in infectious diseases. The surgeon may choose to treat 1 eye at a time on separate days and schedule the patient as the last patient of the day. In addition, the surgeon may consider implementing additional precautions for the operating room staff, such as wearing filter masks during the procedure and evacuating the laser plume.

• Aref AA, Scott IU, Zerfoss EL, Kunselman AR. Refractive surgical practices in persons with human immunodeficiency virus positivity or acquired immune deficiency syndrome. J Cataract Refract Surg. 2010;36(1):153–160.

• Hagen KB, Kettering JD, Aprecio RM, Beltran F, Maloney RK. Lack of virus transmission by the excimer laser plume. Am J Ophthalmol. 1997;124(2):206–211.

Excerpted from BCSC 2020-2021 series: Section 13 - Refractive Surgery. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.