Herpetic ocular infections in solid organ transplantation: A narrative review

Herpetic ocular infections after solid organ transplantation are uncommon but carry disproportionate risks of morbidity, vision loss, and mortality. The widespread use of modern immunosuppressive regimens and antiviral prophylaxis has reshaped their epidemiology, yet it has not eliminated the risk. Cytomegalovirus retinitis remains the most prototypical and vision-threatening manifestation, increasingly presenting as late-onset disease after cessation of prophylaxis or treatment for rejection. Herpetic ocular syndromes, including acute retinal necrosis caused by herpes simplex and varicella-zoster viruses, progress rapidly under T-cell suppression and threaten bilateral vision if not promptly recognized and treated. Epstein-Barr virus retinitis, although rare, highlights the vulnerability of profoundly immunosuppressed recipients to the reactivation of latent viral infections. Risk factors include donor-recipient serostatus mismatch, high-level or lymphocyte-depleting immunosuppression, repeated rejection therapy and comorbidities such as diabetes or chronic kidney disease. Lung recipients appear to be the most vulnerable, followed by kidney and liver recipients. Despite prophylaxis, delayed or atypical presentations are frequent, underscoring the need for structured ophthalmologic vigilance. Prevention requires layered strategies encompassing vaccination, tailored antiviral prophylaxis, careful immunosuppression stewardship and patient education. Early recognition and prompt therapy remain central to preserving sight and optimizing transplant outcomes, as ocular infection is both preventable and a sentinel of systemic disease.