New onset of herpes simplex virus epithelial keratitis after penetrating keratoplasty

New-Onset of Herpes Simplex Keratitis After Blepharoplasty, Case Series and Review of the Literature

PURPOSE

To report 3 cases of new-onset herpes simplex keratitis (HSK) after uncomplicated extraocular plastic surgery and discuss potential risk factors.

METHODS

This case series includes 3 patients who underwent uncomplicated blepharoplastic surgery. Within 2 weeks postoperatively, all patients reported ocular discomfort, and their ophthalmic examinations revealed corneal lesions suspicious of HSK. One case was confirmed as an active herpes infection, and the other 2 cases were clinically diagnosed with HSK. The patients were treated with oral acyclovir and followed up for up to 6 weeks.

RESULTS

All patients demonstrated improvement without sequelae at follow-up visits from 5 days to 4 weeks after initiating acyclovir treatment.

CONCLUSIONS

Risk factors for new-onset HSK after uncomplicated extraocular surgeries may be related to an immunocompromised state, postoperative administration of topical or periocular corticosteroids, or environmental factors such as psychological stress. Ophthalmologists, particularly plastic surgeons, should be vigilant for ocular discomfort following eyelid surgeries and consider the possibility of herpes infection. This report highlights the importance of recognizing and managing HSK in the context of extraocular plastic surgery.

A novel technique of penetrating keratoplasty to prevent intraocular contents extrusion for infectious keratitis

PURPOSE

To evaluate the safety and the effectiveness of our novel penetrating keratoplasty for infectious keratitis.

METHODS

Retrospective, noncomparative, interventional case series of patients with infectious keratitis who received the novel penetrating keratoplasty technique were analyzed. A prepared plastic sheet was located between the diseased cornea and iris-lens diaphragm. After the diseased lesions were removed, the graft was positioned on the plastic sheet and sutured to the recipient bed. The plastic sheet was pulled out from the anterior chamber before the all interrupted sutures were placed. The intra- and post-operative complications, the outcome of the graft and the number of corneal endothelial cells were analyzed.

RESULTS

A total of 82 eyes of 82 patients was included. The mean follow-up period was 29 ± 16 months (range from 13 to 45 months). No intraocular content extrusion, simultaneous cataract extraction and suprachoroidal hemorrhage occurred. Direct contact between the infectious cornea and the graft was successfully avoided. Greater than expected endothelial cell reduction or complications were not found.

CONCLUSIONS

This modified technique effectively prevents the extrusion of intraocular contents while avoiding the direct contact with donor endothelium during the procedure. The occurrence rate of complications such as endothelial cell loss is not higher than the conventional methods.

Herpes simplex virus, varicella-zoster virus and cytomegalovirus keratitis: Facts for the clinician

Keratitis due to Herpes simplex virus (HSK), Varicella-Zoster virus (VZK) and Cytomegalovirus remains a frequent source of concern for many ophthalmologists. They are a frequent cause of emergency consultations at eye care centers and carry the risk of permanent loss of visual acuity or visual quality and/or chronic neurotrophic keratitis, resulting in a significant decrease in the quality of life. HSK and VZK can affect the corneal epithelium, stroma, or endothelium or a combination of layers. In contrast, most cases of CMV keratitis present as isolated endothelitis (CMVE), a clinical entity that has been described within the last 2 decades. These three types of viral keratitis are characterized by a high frequency of recurrences and each new episode increases the risk of sequelae. Hence, ophthalmologists must adapt the treatment to the clinical presentation of each recurrent episode in order to mitigate the immediate consequences of viral replication and the immune response on corneal transparency. In patients with frequent recurrences, preventive long-term antiviral treatment is strongly recommended. However, in some rare cases, continuous exposure to antivirals may promote the emergence of resistant viral strains, which can be difficult to manage. In the future, the introduction of new antiviral drugs, with differing modes of action compared to current medical therapy, could be an alternative until a truly effective preventive solution, such as a vaccine, is available.

Herpes simplex keratoconjunctivitis in the immediate postoperative period after strabismus surgery

The authors describe the case of bilateral herpes simplex keratoconjunctivitis (HSK) following uncomplicated 7 mm bilateral lateral rectus recessions in a 3-year-old child. The recovery was initially unremarkable, and the standard postoperative drops of dexamethasone and chloramphenicol (non-preservative free) were prescribed. The child presented 8 days postoperatively with fever, right upper lid swelling and ptosis. She was admitted for intravenous antibiotics for suspected pre-septal cellulitis. Over the next 2 days, she deteriorated with bilateral lid involvement. An examination under anesthesia (EUA) revealed bilateral corneal epithelial (dendritic and geographical) ulcers with conjunctival erosions and pseudo membranes prompting a diagnosis of HSK. This was confirmed by polymerase chain reaction (PCR) testing. The child recovered within 2 weeks after starting oral and topical antiviral medication. This case highlights the importance of EUA in infections not responding to standard treatment. Although HSK is known to occur after topical steroid use and ocular surgery, we were not able to find any other cases in the literature and believe this is the first reported case of bilateral HSK in the immediate postoperative period after strabismus surgery.

[Modern biotechnological treatment methods of persistent corneal epithelial defects]

The article reviews modern methods of treatment of persistent corneal epithelial defects and considers the factors involved in the development of this pathology, including the limbal stem cell deficiency, which is likely to play the main role. The most promising treatment methods are described, particularly the use of blood derivatives and cell therapy.

Bilateral non-resolving punctate keratitis in a keratoplasty patient

This study aimed to report a case of non-resolving bilateral coarse punctate keratitis in a patient with prior bilateral penetrating keratoplasty. In view of non-response to antivirals, corneal epithelial scraping was carried out, which revealed the presence of microsporidial cysts. The infection resolved after a period of 12 days following the diagnosis, during which steroids were discontinued. Microsporidial keratitis needs to be considered in non-resolving coarse punctate keratitis and microbiologic evaluation is essential to establish the diagnosis.

Distribution of Microbial Keratitis After Penetrating Keratoplasty According to Early and Late Postoperative Periods

Objectives:

The aim of this study was to investigate the distribution of microbial agents in the early and late postoperative periods in patients with microbial keratitis (MK) after penetrating keratoplasty (PK).

Materials and Methods:

The records of 36 patients who were clinically diagnosed as having MK after PK were retrospectively reviewed. Culture results were obtained from microbiology records and the organisms that were produced were noted. A case was deemed as viral keratitis based on the clinical appearance, negative cultures, and response to antiviral treatment. Keratitis development times were evaluated in 2 categories: early (within the first year) and late (after year 1) postoperative period. Mann-Whitney U and Kruskal-Wallis tests were used to compare numerical variables that did not show normal distribution and chi-square test was used to compare categorical variables.

Results:

The majority of MK cases were of bacterial origin (55.5%, n=20), followed by viral (41.7%, n=15) and fungal (2.8%, n=1). Of the 15 cases of early postoperative MK, 10 were bacterial, 4 were viral, and 1 was fungal; however, among cases of late postoperative MK, 10 were bacterial and 11 were viral. The majority (65%) of early and late bacterial infections were caused by gram-positive strains (most commonly staphylococci). Gram-positive bacteria caused keratitis significantly earlier than gram-negative bacteria (p=0.037). Viral and gram-negative bacterial MK was more frequent in the late postoperative period, but the difference was not statistically significant.

Conclusion:

In our study, bacterial keratitis was more common in post-keratoplasty MK than viral and fungal keratitis. Gram-positive bacteria were the most common causative agents. The increased incidence of gram-negative bacterial agents and viral keratitis in the late postoperative period can be explained by long-term topical steroid use.

Incidence and Risk Factors of New Onset Endotheliitis After Cataract Surgery

Purpose

The purpose of this study was to report the characteristics of new-onset endotheliitis after cataract surgery and to identify contributing risk factors.

Methods

In this single-center study, we retrospectively reviewed the clinical records of all patients who underwent uneventful cataract surgery in the Eye Hospital of Wenzhou Medical University between January 2015 and December 2016. Postoperative endotheliitis cases were identified by screening of keywords and individually verified by a cornea specialist. Endotheliitis rates and 95% confidence intervals (CI) were calculated. Cox proportional hazard regression analysis was used to investigate the association between endotheliitis and associated factors.

Results

A total of 20,743 cataract surgeries were performed. Fifty-nine eyes developed endotheliitis after cataract surgery, with an incidence of 0.28%. The mean interval between surgery and first record of endotheliitis was 24.51 ± 9.50 days (range, 5 to 45 days); 45 (76.27%) cases of endotheliitis developed within 30 days. The multiadjusted hazard ratio (HR) associated with increased risk of endotheliitis was 16.1 (95% CI, 3.9 to 66.9; P < 0.001) for patients 76 years of age or older and 10.2 (95% CI, 2.4 to 43.2; P = 0.002) for those 66 to 75 years of age compared with those 65 years of age or younger. Endotheliitis was also associated with history of diabetes mellitus (HR, 1.9; 95% CI, 1.1 to 3.2; P = 0.026).

Conclusions

This study found the incidence of endotheliitis after cataract surgery to be 0.28%. Diabetes mellitus and old age are major risk factors for developing endotheliitis.

Characteristics of New Onset Herpes Simplex Keratitis after Keratoplasty

Purpose

To observe clinical characteristics and treatment outcomes of new onset herpes simplex keratitis (HSK) after keratoplasty.

Methods

Among 1,443 patients (1,443 eyes) who underwent keratoplasty (excluding cases of primary HSK) in Shandong Eye Hospital, 17 patients suffered postoperative HSK. The clinical manifestations, treatment regimens, and prognoses of the patients were evaluated.

Results

The incidence of new onset HSK after keratoplasty was 1.18%. Epithelial HSK occurred in 10 eyes, with dendritic epithelial infiltration in 6 eyes and map-like epithelial defects in 4 eyes. Nine eyes had lesions at the junction of the graft and recipient. Stromal necrotic and endothelial HSK occurred in 7 eyes, presenting map-shaped ulcers in the entire corneal graft and recipient (two eyes) or at the graft-recipient junction (five eyes). Confocal microscopy revealed infiltration of a large number of dendritic cells at the junction of the lesion and transparent cornea. All 10 eyes with epithelial lesions and two eyes suffering stromal lesions of ≤1/3 corneal thickness healed after systematic and local antiviral treatment. Best-corrected visual acuity and corneal graft transparency were restored. For stromal HSK with an ulcer of >1/3 corneal thickness, amniotic membrane transplantation was performed, and visual acuity and graft transparency decreased significantly.

Conclusion

New onset HSK after keratoplasty primarily resulted in epithelial and stromal lesion, involving both the graft and recipient. Effective treatments included antiviral medications and amniotic membrane transplantation. Delayed treatment may lead to aggravated graft opacification.

Epithelial Keratitis After Cataract Surgery

PURPOSE

To evaluate the incidence, related perioperative factors, clinical characteristics, and possible etiologies of epithelial keratitis after cataract surgery.

METHODS

A retrospective chart review of 666 eyes in 666 patients who underwent cataract surgery was performed to evaluate the incidence of epithelial keratitis and related factors in the postoperative period.

RESULTS

Postoperative epithelial keratitis developed in 15 eyes. Eleven of the 15 eyes were diagnosed with herpes simplex keratitis (HSK); 10 of the 11 eyes were diagnosed by polymerase chain reaction, and the remaining 1 eye by clinical diagnosis. All patients diagnosed with HSK had no previous clinical history of the infection before undergoing cataract surgery. Initially, the diagnosis of all 15 eyes was toxic keratitis, but the final diagnosis of 11 of the initial 15 was found to be epithelial herpes keratitis. The incision location was shown to be related to the occurrence of HSK in our study (P < 0.05).

CONCLUSIONS

HSK epithelial keratitis after cataract surgery is a relatively uncommon complication and can be misdiagnosed in its early disease course because of its relative rarity. This study explores the possibility that the temporal corneal penetrating incisional approach used in routine cataract surgery interrupts the corneal nerves and subsequently can trigger reactivation of HSK.

Postoperative herpetic endophthalmitis-A case report

We report a case of herpetic endophthalmitis following cataract surgery. A 65-year-old man underwent uneventful phacoemulsification and vision improved within the first few postoperative days. However, visual loss with an anterior chamber reaction of ++++ and a ++ vitreous cell were noted in the 4th postoperative week. Repeated intravitreal injection of vancomycin and ceftriaxone, pars plana vitrectomy and removal of the intraocular lens (IOL), and the capsular bag were performed sequentially but in vain. Bacterial, mycobacterial, and fungal culture of the IOL and capsular bag demonstrated negative findings. Pathological examination revealed no pathogen but a number of mononuclear cells and several multinuclear giant cells. Serology exam revealed positive herpes simplex virus immunoglobulin (Ig)M and IgG. The intraocular inflammation resolved soon after changing antibiotics to oral valcyclovir.

Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis

BACKGROUND

Eye disease due to herpes simplex virus (HSV) commonly presents as epithelial keratitis which, though usually self-limiting, may persist or progress without treatment.

OBJECTIVES

To compare the relative effectiveness of antiviral agents, interferon, and corneal debridement in the treatment of HSV epithelial keratitis.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 12), PubMed (January 1946 to 31 December 2014), EMBASE (January 1980 to 31 December 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to 31 December 2014), System for Information on Grey Literature in Europe (OpenGrey) (January 1995 to 31 December 2014), BIOSIS (January 1926 to 5 May 2014), Scopus (January 1966 to 31 December 2014), Japan Science and Technology Institute (J-Global) (January 1975 to 31 December 2014), China National Knowledge Infrastructure (CNKI) (January 1979 to 31 December 2014), British Library's Electronic Table of Contents (Zetoc) (January 1993 to 7 May 2014). We looked for trials listed on the the metaRegister of Controlled Trials (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), Chinese Clinical Trial Registry, the U.S. Food and Drug Administration (FDA) (www.fda.gov/), National Institute for Health and Clinical Excellence (NICE) (www.

EVIDENCE

nhs.uk) and the European Medicines Agency (EMA) (www.ema.europa.eu/ema/) as of 31 December 2014. There were no language or date restrictions in the search for trials. We also culled literature digests and conference proceedings as of 15 April 2014. There were no language or date restrictions in the search for trials.

SELECTION CRITERIA

Randomised and quasi-randomised trials of HSV dendritic or geographic epithelial keratitis were included that reported the proportion of eyes healed at one week, two weeks, or both after enrolment.

DATA COLLECTION AND ANALYSIS

We tabulated data on study characteristics, risk of bias, and outcomes and used direct comparisons to estimate a risk ratio (RR) and, when feasible, a hazard ratio (HR) with a 95% confidence interval (CI). Heterogeneity was assessed by an inconsistency index. A multiple treatment comparison meta-analysis consolidated direct and indirect comparisons of relative healing at 14 days.

MAIN RESULTS

One hundred thirty-seven studies involving 8333 eyes met the inclusion criteria. Placebo-controlled studies were heterogeneous in comparison with idoxuridine (RR 1.74; 95% CI 1.03 to 2.91) and few in number for vidarabine (RR 1.81; 95% CI 1.09 to 3.01), interferon (RR 1.32; 95% CI 1.06 to 1.64), and debridement. Vidarabine (RR 1.13; 95% CI 1.02 to 1.25), trifluridine (RR 1.30; 95% CI 1.18 to 1.43), acyclovir (RR 1.23; 95% CI 1.14 to 1.34), and brivudine (RR 1.34; 95% CI 1.18 to 1.51) were more effective than idoxuridine. Trifluridine (RR 1.17; 95% CI 1.03 to 1.32) and acyclovir (RR 1.11; 95% CI 1.03 to 1.19) were more effective than vidarabine. No significant differences in healing emerged among trifluridine, acyclovir, brivudine, and foscarnet although few studies compared brivudine or foscarnet with other antivirals. Any potential advantage of ganciclovir compared to acyclovir was mitigated by study heterogeneity and possible publication bias. Only one study evaluated the joint use of two topical antivirals. In a limited number of studies, oral acyclovir (RR 0.92; 95% CI 0.79 to 1.07) or the combination of oral acyclovir with a topical antiviral (RR 1.36; 95% CI 0.68 to 2.74) appeared as effective as a single topical antiviral agent. Compared to topical antiviral monotherapy, the combination of an antiviral with either interferon or debridement had inconsistent effects on expediting healing and improving outcome.

AUTHORS' CONCLUSIONS

Placebo-controlled studies of HSV epithelial keratitis are limited to superseded interventions. Trifluridine and acyclovir are more effective than idoxuridine or vidarabine and similar in therapeutic effectiveness. Brivudine and foscarnet do not substantially differ in effectiveness from trifluridine or acyclovir. Ganciclovir is at least as effective as acyclovir. The addition of interferon to a nucleoside antiviral agent and the combination of debridement with antiviral treatment need to be further assessed to substantiate any possible advantage in healing.

Ocular surface deficits contributing to persistent epithelial defect after penetrating keratoplasty

PURPOSE

To determine the ocular surface deficits contributing to persistent epithelial defect (PED) after penetrating keratoplasty (PKP).

METHODS

Four ocular surface deficits that contribute to PED and their corrective measures were reviewed in 11 eyes of 11 patients with PED after PKP.

RESULTS

Among these 11 eyes, PED developed early in 8 eyes and late in 3 eyes after PKP. They all had more than 2 ocular surface deficits, with infrequent blinking (11 eyes) and lagophthalmos (9 eyes) being more common. Proper corrective measures resulted in rapid epithelialization in 1 week (1 eye), 2 weeks (9 eyes), and 3 weeks (1 eye) via insertion of a bandage contact lens to maintain tear film for treating infrequent blinking (4 eyes), tarsorrhaphy to correct nocturnal lagophthalmos (2 eyes), and fornix reconstruction to eliminate pathogenic symblepharon (4 eyes). During the follow-up of 22.1 ± 7.6 months after healing of PED, 8 eyes retained a stable and clear graft, whereas 3 eyes with more ocular surface deficits had recurrent PED and graft failure develop. Two of the latter were corrected by a repeat PKP combined with oral mucosal graft to correct the remaining cicatricial eyelids.

CONCLUSIONS

Besides the neurotrophic state and aqueous tear deficiency dry eye common in this cohort, infrequent blinking, lagophthalmos, and pathogenic symblepharon also contribute to PED after PKP. Proper corrective measures and vigilant follow-up are crucial for maintaining PKP graft survival in these severe cicatricial ocular surface diseases.

Unusual clinical presentations of new-onset herpetic eye disease after ocular surgery

PURPOSE

To report five cases of new-onset herpetic eye disease with unusual presentation after ocular surgery.

METHODS

Herpetic eye disease was suspected in five cases, three after cataract surgery and two after lamellar corneal transplantation surgery. Of these, four cases presented within 2-6 weeks of surgery. The clinical presentation was in the form of an epithelial defect, suspected epithelial down growth, graft oedema with unexplained anterior chamber inflammation and graft-host interface infection. A swab for viral detection with real-time polymerase chain reaction was performed in all the described cases.

RESULTS

Herpes simplex disease was detected in all cases. All cases responded to the antiherpetic medications.

CONCLUSIONS

Our study shows that new-onset herpetic eye disease may occur after cataract surgery and lamellar corneal transplantation, and a high index of suspicion may be necessary for the diagnosis in such cases.

Ocular herpes simplex virus: how are latency, reactivation, recurrent disease and therapy interrelated?

Most humans are infected with herpes simplex virus (HSV) type 1 in early childhood and remain latently infected throughout life. While most individuals have mild or no symptoms, some will develop destructive HSV keratitis. Ocular infection with HSV-1 and its associated sequelae account for the majority of corneal blindness in industrialized nations. Neuronal latency in the peripheral ganglia is established when transcription of the viral genome is repressed (silenced) except for the latency-associated transcripts and microRNAs. The functions of latency-associated transcripts have been investigated since 1987. Roles have been suggested relating to reactivation, establishment of latency, neuronal protection, antiapoptosis, apoptosis, virulence and asymptomatic shedding. Here, we review HSV-1 latent infections, reactivation, recurrent disease and antiviral therapies for the ocular HSV diseases.

Ocular herpes simplex virus type 1: is the cornea a reservoir for viral latency or a fast pit stop?

PURPOSE

To present a review supporting and refuting evidence from mouse, rabbit, nonhuman primate, and human studies of herpes simplex virus type 1 (HSV-1) concerning corneal latency.

METHODS

More than 50 research articles on HSV-1 published in peer-reviewed journals were examined.

RESULTS

Infectious HSV-1 has been found in mouse denervated tissues and in tissues with negative cultures from the corresponding ganglion. However, the different mouse strains have shown varied responses to different strains of HSV, making it difficult to relate such findings to humans. Rabbit studies provide excellent evidence for HSV-1 corneal latency including data on HSV-1 migration from the cornea into the corneoscleral rim and on the distribution of HSV-1 DNA in the cornea. However, the available methods for the detection of infectious HSV-1 may not be sensitive enough to detect low-level infection. Infectious HSV-1 has been successfully isolated from the tears of nonhuman primates in the absence of detectable corneal lesions. The recurrence of corneal ulcers in nonhuman primates before the appearance of infectious HSV-1 in tears suggests that the origin of the HSV-1 is the cornea, rather than the trigeminal ganglion. Human studies presented evidence of both ganglion and corneal latency.

CONCLUSIONS

Understanding HSV-1 disease progression and the possibility of corneal latency could lead to more effective treatments for herpetic keratitis. However, it is unlikely that operational latency in the cornea will be definitively proven unless a new method with higher sensitivity for the detection of infectious virus is developed.

Corneal latency and transmission of herpes simplex virus-1

The transmission of herpes simplex virus (HSV)-1 by corneal transplantation has rarely been reported. It is believed that these cases have resulted either from reactivated virus traveling from the trigeminal ganglion to the cornea or from latent HSV-1 in the donor cornea itself. Studies of long-term viral presence in corneal tissue have sought to determine whether there is evidence of true non-neuronal latency, although there are problems in its definition. Recent studies provide new insights into neuronal latency, while similar HSV-1 gene regulation in the cornea may implicate corneal latency in pathophysiology and as a potential risk for transplant recipients. This issue has led to concerns over eye banking, which currently screens for other infectious agents but not HSV-1. Here we review the literature regarding corneal latency and the transmission of HSV-1.

Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis

BACKGROUND

Eye disease due to herpes simplex virus (HSV) commonly presents as epithelial keratitis.

OBJECTIVES

To compare the relative effectiveness of antiviral agents, interferon, and corneal débridement in the treatment of acute HSV epithelial keratitis.

SEARCH STRATEGY

We searched CENTRAL (The Cochrane Library 2010, Issue 4), MEDLINE (January 1950 to October 2010), EMBASE (January 1980 to October 2010), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to October 2010), Zetoc (British Library's Electronic Table of Contents), System for Information on Grey Literature in Europe (openSIGLE), Biosciences Information Service (BIOSIS), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), Japan Information Center of Science and Technology (JICST-EPlus), and China Academic Journals database (CAJ) via China National Knowledge Infrastructure (CNKI) with citations confirmed using China/Asia On Demand (COAD). There were no language or date restrictions in the search for trials. All databases except CNKI and COAD were last searched on 27 October 2010, CNKI and COAD were searched on 1 April 2010. We also searched literature digests, conference proceedings and reference lists.

SELECTION CRITERIA

Of 152 eligible studies,106 comparative treatment trials involving 5872 eyes with dendritic or geographic epithelial keratitis were analysed for corneal healing over two weeks.

DATA COLLECTION AND ANALYSIS

Interventions were compared at 14 days after trial enrolment by calculating a risk ratio (RR) that was adjusted with indirect RR, assessed by an inconsistency index (I(2) ) and supplemented by a seven-day RR and a hazard ratio (HR).

MAIN RESULTS

Idoxuridine, though uncertainly better in healing outcome than control because of few trials with 14-day follow up, allowed earlier corneal re-epithelialisation. Vidarabine resulted in a significantly better outcome than placebo in one trial (RR 1.96; 95% CI 1.10 to 3.49). Compared to idoxuridine, in combined direct and indirect analyses, vidarabine (RR 1.11; 95% CI 1.03 to 1.19), trifluridine (RR 1.31; 95% CI 1.20 to 1.42), acyclovir (RR 1.23; 95% CI 1.16 to 1.31), brivudine (RR 1.38; 95% CI 1.18 to 1.61), and ganciclovir (RR 1.40; 95% CI 1.25 to 1.57) were significantly more effective. Trifluridine (RR 1.12; 95% CI 1.04 to 1.21) and acyclovir (RR 1.11; 95% CI 1.05 to 1.19) appeared more effective than vidarabine. No significant differences were found in comparisons between acyclovir, trifluridine and brivudine. The comparison of ganciclovir to acyclovir was limited by heterogeneity and possible publication bias. The joint use of two topical antivirals (RR 1.00; 95% CI 0.89 to 1.12) and the use of oral acyclovir alone (RR 0.92; 95% CI 0.79 to 1.07) or combined with a topical antiviral (RR 1.08; 95% CI 0.99 to 1.17) appeared as effective as topical antiviral therapy. Compared to antiviral monotherapy, the combination of an antiviral with interferon (RR 1.03; 95% CI 0.99 to 1.07) or with débridement (RR 1.04; 95% CI 0.95 to 1.14) did not yield significantly better outcomes but may have accelerated healing. The corneal epithelial healing outcome was improved when antiviral therapy was added to débridement (RR 1.21; 95% CI 1.04 to 1.42).

AUTHORS' CONCLUSIONS

Trifluridine and acyclovir are more effective than idoxuridine or vidarabine, and similar in therapeutic effectiveness. Brivudine and ganciclovir are at least as effective as acyclovir. While not improving outcome, the combination of interferon and an antiviral agent may speed healing. The effectiveness of corneal epithelial débridement is improved by an antiviral agent.

The effect of topical ocular corticosteroid administration in dogs with experimentally induced latent canine herpesvirus-1 infection

Recurrent herpes simplex virus-1 (HSV-1) ocular infection is a frequent cause of morbidity and blindness. Factors that trigger viral reactivation are poorly understood and the role of topical ocular corticosteroid administration in the development of recurrent HSV-1 ocular disease is not clear. Clinical reports and epidemiological studies suggested topical corticosteroids may reactivate latent HSV-1 and result in recrudescent ocular disease; however, experimental studies to establish this causal relationship produced inconsistent results. The previous experimental studies were performed by infecting unnatural host species with HSV-1 and aspects of viral behavior and reactivation within these animals may differ from the host for which the virus is adapted. The purpose of the study reported here was to determine if topical ocular corticosteroid administration results in viral reactivation and recrudescent ocular disease in a host-adapted pathogen animal model of HSV-1 recurrent ocular disease. Canine herpesvirus-1 (CHV-1) is a corticosteroid-sensitive alphaherpesvirus that is biologically related to HSV-1 and induces similar ocular lesions in canids during recurrent infection. A randomized, masked, placebo-controlled, crossover study was performed. Primary ocular CHV-1 infection was experimentally induced in mature specific pathogen-free beagles by topical ocular inoculation and the presence of reactivatable latency was later confirmed by administration of an immunosuppressive dosage of systemic corticosteroid to the dogs. Twelve months following experimental CHV-1 reactivation, dogs were administered either topical ocular prednisolone acetate (1.0% ophthalmic suspension, one drop in both eyes, four times daily) or placebo (artificial tear solution, one drop in both eyes, four times daily) for 28 days. After a 14 day washout period, the treatment groups were reversed and study agents administered for an additional 28 days. Ophthalmic examinations, in vivo ocular confocal microscopy, real-time quantitative CHV-1 polymerase chain reaction assays, and CHV-1 serum neutralization antibody titers were performed at regular intervals throughout the study. Viral reactivation was not detected in dogs administered topical ocular prednisolone or placebo as determined by clinical ocular disease recrudescence, in vivo ocular confocal microscopic findings, ocular viral shedding, and serologic response. Similar to other animal models of recurrent HSV-1 ocular infection, the behavior of latent CHV-1 in dogs may differ from HSV-1 in humans; however, results of the present study suggest administration of topical ocular prednisolone at the evaluated drug concentration, dosing frequency, and treatment duration is not likely to result in detectable reactivation of latent CHV-1 in experimentally infected dogs. This may be attributed to insufficient systemic absorption of locally administered corticosteroid to reactivate latent virus and produce recurrent disease. Crystalline corneal opacities that were apparently not associated with viral reactivation were detected by clinical examination and in vivo confocal microscopy in two dogs during topical ocular prednisolone administration. The crystalline keratopathy may have resulted from corneal degeneration associated with metaherpetic disease, corticosteroid administration, or a combination of both factors.

Herpetic keratitis after descemet stripping automated endothelial keratoplasty for failed graft

OBJECTIVES

To report a case of herpetic epithelial keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK) for a failed graft.

METHODS

A 31-year-old female patient underwent DSAEK for failed graft in left eye. She previously had undergone penetrating keratoplasty for keratoconus in that eye.

RESULTS

One week after DSAEK, the patient presented with pain in left eye. The cornea showed two epithelial defects with dendritic edges that involved the penetrating keratoplasty graft host junction and showed positive fluorescein staining. Diagnosis of herpes simplex virus keratitis was made and the patient was started on oral acyclovir and topical trifluiridine. The epithelial lesions showed complete resolution in 3 days.

CONCLUSIONS

Herpes simplex virus epithelial keratitis can occur after DSAEK for failed grafts even in the absence of previous history of herpes simplex virus infection and should be considered in the differential diagnosis of postoperative epithelial defects.

New-onset herpes simplex virus keratitis after cataract surgery

We report the case of a 34-year-old man who had uncomplicated cataract surgery in his left eye. Medical history was significant for atopic dermatitis, requiring oral immunosuppressive medications. Two days after the surgery, the patient presented with pain, photophobia, decreased vision, and a small corneal abrasion. On postoperative day 5, the patient returned with left upper lid vesicular lesions and 2 corneal dendrites. Corrected vision was 20/100 OS, with intraocular pressure of 18 mm Hg and 1+ pigmented cells in the anterior chamber. Cultures of the lid lesions revealed herpes simplex virus (HSV) type 1. The patient was placed on oral acyclovir 800 mg 5 times a day. By day 8, the dendrites had resolved, and by day 15, the lid lesions healed over. HSV keratitis is an uncommon complication after cataract surgery. Ophthalmologists should be aware of the possibility of developing HSV keratitis even after the most routine cataract extraction.

Herpes Simplex Keratitis After Cataract Surgery

PURPOSE

Herpetic keratitis is a rare complication of cataract surgery. We describe 3 cases of herpes simplex keratitis after cataract surgery in eyes with no clinical history of this disease.

METHODS

Three patients underwent uneventful phacoemulsification of cataract with intraocular lens implantation. All were treated postoperatively with topical steroids. On subsequent development of corneal dendritic epithelial lesions in the operated eyes, the corticosteroids were replaced by treatment with topical acyclovir.

RESULTS

The first postoperative day was uneventful. Corneal dendritic epithelial lesions were observed 1-5 weeks postoperatively and healed without sequelae after topical acyclovir treatment.

CONCLUSIONS

In view of the surgical trauma along with the topical corticosteroid treatment commonly prescribed after cataract surgery, physicians should be aware of the possible development of herpetic epithelial keratitis even in patients with no clinical history of this disease.

Epithelial herpetic simplex keratitis recurrence and graft survival after corneal transplantation in patients with and without atopy

PURPOSE

To compare the incidence of herpes simplex virus (HSV) epithelial recurrence and graft survival after penetrating keratoplasty (PK) in patients with and without self-reported atopy.

DESIGN

Retrospective cohort comparative study.

METHODS

SETTING

Cornea Service, Wills Eye Hospital.

STUDY POPULATION

Patients who presented with previously diagnosed ocular HSV between March 2003 and March 2004 and who underwent primary PK for ocular HSV at the Cornea Service. From the 58 patients invited, 49 patients (50 eyes) were included. Nine patients were ineligible in accordance with the exclusion criteria: no active classic HSV episode before PK, immunosuppression, less than one year of follow-up, previous history of PK before presentation at the Service. Eligible patients filled out a questionnaire regarding their history of atopic disease, considering: presence of allergic rhinitis, asthma, or atopic dermatitis. Ocular history was obtained through chart review. main outcome measures: Incidence of epithelial HSV recurrences and corneal graft survival in both groups.

RESULTS

Each group (atopic and nonatopic) included 25 eyes. The atopic patients had a mean incidence of 0.07 episode/eye year (SD +/- 0.9) compared with 0.12/eye year (standard deviation [SD] +/- 0.21) in the nonatopics (P = .002). At 10 years of follow-up, the survival rate in the atopics was of 92% and in the nonatopics was of 79% (P = .88).

CONCLUSIONS

Nonatopics had significantly more epithelial recurrences after PK compared to atopics; however, both groups presented low incidences of recurrences and high graft survival rates.

Specific antibody production in herpes keratitis: intraocular inflammation and corneal neovascularisation as predicting factors

PURPOSE

The purpose of the study is to investigate whether analysis of specific antibody synthesis can aid the diagnosis of herpes keratitis.

METHODS

Aqueous humor was collected from 39 patients with presumed recurrent herpes keratitis, including 23 consulting for keratitis and 16 patients scheduled for penetrating keratoplasty. Local antibody production was ascertained by analysis of paired aqueous humor/serum samples, using a modified micro-ELISA technique.

RESULTS

Local production of antibodies was found in 32 patients (82%): anti-herpes simplex virus (HSV) antibodies in 26 (67%) and anti-varicella zoster virus (VZV) antibodies in 11 (28%). Twenty of 23 patients with active keratitis (87%), and 12 of 16 undergoing keratoplasty (75%), tested positive. Five patients had local production of both anti-HSV and anti-VZV antibodies, whereas seven patients tested negative. Local antibody production was significantly associated with intraocular inflammation (P<0.05), corneal neovascularisation (P<0.05), and positive response to anti-viral treatment (P<0.05). No complications were encountered in sampling aqueous humor.

CONCLUSIONS

Assessment of local anti-HSV and -VZV antibody production is a safe and reliable diagnostic procedure for recurrent herpes keratitis. It might be particularly helpful in patients presenting with intraocular inflammation and neovascularisation since it discriminates between herpes and non-herpes pathologies and may therefore be useful for preventive and therapeutic strategies.