Decision-making in Herpes Simplex viral keratitis grafts

Background

Keratoplasty after healed herpes simplex viral keratitis is a challenge due to problems arising preoperatively, intraoperatively, and postoperatively.

Purpose

In this video, we describe the necessary challenges and the steps, which can be taken to prevent and manage those cases of healed herpes simplex virus (HSV) keratitis that would require a keratoplasty.

Synopsis

The video talks about both the typical and atypical features of HSV keratitis, clinical examination, the scenarios which would require a keratoplasty, problems arising intraoperatively and how to manage them, and finally how to approach these high-risk grafts postoperatively.

Highlights

Our video highlights the diagnosis of HSV keratitis, which cases are ready for surgery, and preoperative, intraoperative, and postoperative considerations before corneal transplantation in healed HSV keratitis. Decision-making before corneal transplant in HSV grafts can become more structured if these points are followed.

Video Link

https://youtu.be/xMT7Ki8vuc4.

Outcome of Lamellar Graft Patching for the Treatment of Noninfectious Corneal Perforations

PURPOSE

The aims of this study were to evaluate the clinical outcome of lamellar graft patching used for treating noninfectious corneal perforations and to determine the clinical factors affecting tectonic integrity.

METHODS

This retrospective study includes a total of 71 eyes of 67 patients who underwent lamellar graft patching for the treatment of corneal perforations due to persistent epithelial defects secondary to limbal stem cell deficiency (LSCD, 21 eyes; 29.6%), peripheral ulcerative keratitis (17 eyes; 23.9%), neurotrophic keratitis due to herpes simplex keratitis (HSK, 14 eyes; 19.7%), and other causes (19 eyes; 26.8%). We evaluated the tectonic integrity of the globe, visual outcomes, and postoperative complications.

RESULTS

Tectonic integrity was achieved in 53 eyes (74.6%). The survival proportions of eyes that achieved clear grafts were 77.8% and 65.2% at 12 and 24 months, respectively. Graft failure was observed in 19 eyes (26.8%). The survival rate of tectonic integrity and eyes that finally achieved a clear graft was significantly worse in eyes with LSCD compared with those without ( P < 0.001). The logarithm of minimal angle resolution improved significantly from 1.79 ± 0.98 to 1.22 ± 0.87 at 12 months and 1.08 ± 0.81 at 24 months. Postoperative complications included cataract formation (32 eyes, 45.1%), intraocular pressure rise (23 eyes, 32.4%), recurrent perforations (15 eyes, 21.1%), infectious keratitis (14 eyes, 19.7%), recurrence of herpes simplex keratitis (7 eyes, 9.9%), and traumatic graft dehiscence (1 eye, 1.4%).

CONCLUSIONS

Lamellar graft patching is an effective and safe surgical treatment for noninfectious corneal perforations; however, careful attention to severe complications is necessary, especially in eyes with LSCD.

Evidence in the prevention of the recurrence of herpes simplex and herpes zoster keratitis after eye surgery

OBJECTIVE

Herpetic keratitis, either due to herpes simplex keratitis (HSK) or herpes zoster ophthalmicus (HZO), can recur after eye surgery.º Prophylaxis is postulated as necessary to avoid it. The objective of this study was to review the scientific evidence on the preventive methods used in the perioperative period in patients previously affected by HSK/HZO.

METHODS

An exhaustive search was carried out in the PubMed and Web of Science databases to identify relevant articles on prophylaxis and risk of recurrence of HSK/HZO in patients undergoing eye surgery up to 31 December 2019.

RESULTS

There is strong evidence that oral prophylaxis should be recommended after penetrating keratoplasty in patients who have previously had HSK/HZO. For other types of surgery, the evidence is less compelling. However, a latent period of inactivity should be considered between disease and oral prophylaxis.

CONCLUSIONS

Penetrating and lamellar keratoplasty, corneal crosslinking, cataract surgery, and photorefractive and phototherapeutic surgery cause an alteration of the subbasal nerve plexus of the cornea. Due to surgical trauma, as well as the modulation of the ocular immune response caused by steroids applied in the postoperative period, it is possible to induce the reactivation of HSK/HZO, which is common in some cases. Within this article, we discuss the available evidence for HSK/HZO prophylaxis in eye surgery. Further studies are necessary to define the real risk of HSK/HZO recurrence after ocular surgeries, particularly in cataract surgery, and to confirm the efficacy of perioperative prophylaxis with anti-HSK/HZO antivirals.

Long-term Outcomes of Pediatric Penetrating Keratoplasty for Herpes Simplex Virus Keratitis

PURPOSE

To analyze the characteristics and long-term outcomes of patients that underwent pediatric penetrating keratoplasty (PPK) for herpes simplex virus (HSV) keratitis.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

Observational report of outcomes and findings for 9 patients with history of HSV keratitis that underwent PPK and were followed in a single institution. Difference between the median preoperative and final best-corrected visual acuity (BCVA) was assessed and the outcomes are reported.

RESULTS

We included 9 eyes; median age at the moment of the PPK was 14 years. The median initial BCVA was 20/400 (range 20/60 to hand motion) and final was 20/50 (range 20/30 to 20/400) (P < .05). Follow-up was a median of 94 months. Complications in these patients included glaucoma (1), graft rejection (1), recurrence of disease (1), and amblyopia (3). No graft failures were present.

CONCLUSION

The long-term outcomes with PPK for HSV keratitis in children provide improvement in BCVA when not compromised by amblyopia.

Clinical evaluation of deep anterior lamellar keratoplasty using glycerol-cryopreserved corneal tissues for refractory herpetic stromal keratitis: An observational study

The study aimed to evaluate the therapeutic effects of deep anterior lamellar keratoplasty (DALK) using glycerol-cryopreserved corneal tissues (GCCTs) in patients with refractive herpes simplex keratitis (HSK). This article was a retrospective, noncomparative, and interventional case series. Patients with HSK underwent DALK using GCCTs at Shanghai Tongji Hospital from 2012 to 2015. The best spectacle corrected visual acuity, recurrent inflammation, graft status, postoperative central graft thickness, and pre/postoperative complications were detected. The follow-up ranged from 24.4 ± 5.6 months (range: 16-38 months). Overall, the best spectacle corrected visual acuity was increased from HM/10 cm to 0.15 before surgery to 0.41 ± 0.14 (range: 0.1-0.8; P < 0.05) at 12 months postoperatively. Intraoperative microperforation occurred in 4 eyes (14.81%), and rejection episodes were encountered in 3 of 27 eyes (11.1%), and all of the eyes reversed. HSK recurred in 2 eyes (7.41%), 1 eye with repeated recurring HSK, and eventually led to perpetual corneal opacity and the patient refused a retransplantation. The mean entire corneal thickness was 0.519 ± 0.018 mm (range: 0.5-0.56 mm) and the mean graft thickness was 0.405 ± 0.033 mm (range: 0.35-0.47 mm) in the final follow-up. The DALK using GCCTs was proven to be an effective and safe therapy in treating refractory HSK.

[Lamellar minikeratoplasty for recurrent herpes keratitis in the late post-LASIK period]

The article presents a case report of sutureless lamellar minikeratoplasty for progressive corneal ulceration associated with herpes simplex infection in the late period after LASIK.

[Severe infectious keratitis in renal transplant patient: a case report]

Keratitis occurring in renal transplant patients are often severe, with difficult management. We describe the case of a renal transplant patient, 44 year-old man, with history of recurrent herpetic keratitis, which developed an impending corneal perforation. Conjunctival smear showed the presence of amoebic cysts. Anti-amoebic treatment was undertaken in addition with oral aciclovir, and a therapeutic penetrating keratoplasty was performed. An ulceration of the graft occurred within five months. Ocular samples showed the presence of Candida albicans. Despite aggressive antifungal therapy, he required a second therapeutic penetrating keratoplasty for graft perforation. One month later, we noted a recurrence of the ulcer with corneal thinning which evolved to perforation.

[Therapeutic penetrating keratoplasty in herpes infected eye]

PURPOSE

To report the clinical results, the postoperative course and the complications observed after therapeutic penetrating keratoplasty in herpetic keratitis.

METHODS

Eleven eyes with herpetic keratitis (11 patients) that underwent therapeutic keratoplasty between September 2002 and September 2008 were included in this study. The eyes were evaluated retrospectively with respect to the anatomic success rate, the graft clarity, the visual prognosis and the postoperative complications.

RESULTS

The mean follow-up was 13.7 months. Nine cases presented with corneal perforation and two cases with descemetocele. Anatomic repair was obtained in 11 eyes (100%). The graft transparency rate was 54.5%. A final visual acuity equal to or better than 1/10 was achieved in 45.45%. Major causes of failure of corneal graft included recurrent disease (n = 1), glaucoma (n = 1), graft rejection (n = 2) and early irreversible edema of the graft (n = 1).

CONCLUSION

The prognosis of therapeutic penetrating keratoplasty in herpetic eye disease can only be improved with proper postoperative care and optimal management of immunologic and virologic complications.

Therapeutic effect of amniotic membrane in persistent epithelial defects and corneal ulcers in herpetic keratitis

Amniotic membrane transplantation (AMT) promotes rapid epithelialization and reduces stromal inflammation and ulceration in HSV-1 keratitis. 18 patients with non-healing epithelial defect or corneal ulcer caused by herpetic keratitis were included in the study. All patients were treated by AMT. Corneal epithelial cells in patients suffering from herpetic keratitis secreted 5+/-4.8 pg/ml of IL-1alpha and 0.16+/-0.47 pg/ml of IL-1beta (mean+/-SD). IL-1alpha level was significantly higher as compared to controls (p<0.005). Amniotic membranes that were used to treat investigated patients contained 339.87+/-105 pg/ml of IL-1ra. In herpetic keratitis pro-inflammatory cytokine IL-1alpha is secreted from corneal epithelial cells in significantly higher level then in controls. Beneficial effect of the AMT in such patients could be explained by the fact that AM secretes its natural antagonist IL-1ra.

Acyclovir therapy in prevention of recurrent herpetic keratitis following penetrating keratoplasty

PURPOSE

To compare systemic vs topical acyclovir therapy for the prevention of recurrence of herpetic keratitis following penetrating keratoplasty (PK).

DESIGN

A retrospective observational study.

METHODS

Patients who underwent PK for herpetic eye disease (HED) and prophylactically received acyclovir therapy postoperatively, either systemically (26 eyes) or topically (29 eyes), were analyzed. The main parameters evaluated were recurrence of herpetic keratitis, graft rejection, visual acuity, and graft survival rate.

RESULTS

Mean average follow-up period was 24.7 +/- 3.6 months and 23.5 +/- 2.3 months in the systemic and topical group, respectively (P = 0.73). The average duration of prophylactic antiviral therapy in systemic group was 16.1 +/- 4.8 months and in topical group was 15.1 +/- 3.5 months (P = .59). Recurrence of herpetic keratitis was seen in 12% in the systemic group compared to 55% in the topical group (P < .001). More eyes in topical group 15 (52%) had rejection episodes than in the systemic group 5 (19%) (P < .001). A best-corrected visual acuity of > or = 20/40 was achieved in 31% and 7% eyes in the systemic and topical group, respectively, at the end of two years (P = .002). The clear graft survival rate in the systemic and topical acyclovir receiving group was 96.2% vs 86.2% at 12 months, and 88.5% vs 65.5% at 24 months, respectively.

CONCLUSION

Systemic acyclovir is more effective than topical acyclovir in achieving better graft outcomes after PK for HED.

HSV keratitis: histopathologic predictors of corneal allograft complications

PURPOSE

To identify histopathologic features predictive for adverse allograft outcomes following penetrating keratoplasty for herpes simplex virus (HSV) keratitis.

METHODS

Retrospective, interventional case series of 62 consecutive patients with HSV keratitis who underwent penetrating keratoplasty at the Kellogg Eye Center from 1990 through 2000. A detailed chart review and review of the histopathology of the excised corneal button were performed to identify associations between clinical data (disease activity, vascularity, adverse allograft outcomes) and histopathologic data (inflammation, neovascularization, biomarkers). The main outcome measure was to find histopathologic features that may predict HSV recurrence, allograft rejection, or failure.

RESULTS

Although 81% of patients had clinically quiescent disease, histopathology revealed that 74% had active corneal inflammation, a finding that was associated with the presence of clinical neovascularization (P = .01). Histopathologic inflammation was a risk factor for allograft rejection (P = .02) but not failure (P = .98) or HSV recurrence (P = .45). Histopathologic neovascularization did not predict rejection (P = .19) but did predict failure (P = .002) and HSV recurrence (P = .05). Biomarkers, including HLA-DR, ICAM-1, and IL-8(CXC) and MCP-1 (CC) chemokines, were all significantly increased in fresh corneal specimens demonstrating moderate to severe inflammation. IL-10 treatment ex vivo significantly inhibited HLA-DR, IL-8 (P = .006), and MCP-1 (P = .01) but did not reduce ICAM-1 expression.

CONCLUSION

Histopathologic inflammation, neovascularization, and the presence of specific biomarkers are risk factors for corneal allograft morbidity.

Effect of prophylactic oral acyclovir after penetrating keratoplasty for herpes simplex keratitis

PURPOSE

To determine the effect of routine use of prophylactic oral acyclovir after penetrating keratoplasty (PK) for herpes simplex virus (HSV) keratitis on recurrence, rejection, and graft failure rates.

METHODS

Records from 70 consecutive patients who underwent PK for HSV keratitis at the W.K. Kellogg Eye Center between August 1, 1990, and December 31, 2000, were reviewed. Data collected included preoperative disease activity, duration, host vascularity, pre- and postoperative vision, and antiviral use. Particular attention was given to all episodes of HSV recurrence, graft rejection, and failure.

RESULTS

Fifty-six patients (80%) were treated with prophylactic oral acyclovir after surgery. This cohort experienced fewer episodes of rejection (P = 0.006) and better overall graft survival (P = 0.04) than those who were not treated with prophylactic oral antivirals. There was no statistically significant difference in recurrence-free survival between the 2 groups (P = 0.22). Cox regression analysis failed to identify any single variable as a statistically significant predictor of recurrence, rejection, or graft failure.

CONCLUSIONS

Prophylactic oral acyclovir use after PK for HSV keratitis is associated with decreased episodes of rejection and improved graft survival.

Use of a "small-bubble technique" to increase the success of Anwar's "big-bubble technique" for deep lamellar keratoplasty with complete baring of Descemet's membrane

PURPOSE

To describe a quick and simple "small-bubble" technique to immediately determine the success of attaining complete Descemet's membrane (DM) separation from corneal stroma through Anwar's "big-bubble" technique of deep anterior lamellar keratoplasty (DALK) for complete stromal removal.

METHODS

A partial trephination was followed by a lamellar dissection of the anterior stroma. Deep stromal air injection was then attempted to achieve the big bubble to help separate the stroma from the DM. To confirm that a big bubble had been achieved, a small air bubble was injected into the anterior chamber (AC) through a limbal paracentesis. If the small bubble is then seen at the corneal periphery, it confirms that the big-bubble separation of DM was successful because the convex nature of the bubble will cause it to protrude posteriorly, forcing the small AC bubble to the periphery. If the small AC bubble is not seen in the corneal periphery, this means that it is present in the centre, beneath the opaque corneal stroma, and therefore the big bubble has not been achieved.

RESULTS

We used the small-bubble technique to confirm the presence of the big bubble in three (one keratoconus, one interstitial keratitis and one dense corneal scar) out of 41 patients who underwent DALK. The small-bubble technique confirmed that the big bubble was achieved in the eye of all three patients. Complete stromal removal with baring of the DM was achieved, and postoperatively all three eyes achieved best corrected vision of 6/6.

CONCLUSION

The small-bubble technique can be a useful surgical tool for corneal surgeons attempting lamellar keratoplasty using the big-bubble technique. It helps in confirming the separation of DM from the deep stroma, which is important in achieving total stromal replacement. It will help to make the transition to lamellar keratoplasty smoother, enhance corneal graft success and improve visual outcomes in patients.

The Boston keratoprosthesis in herpetic keratitis

OBJECTIVE

To evaluate the role of an artificial cornea (Boston Keratoprosthesis [KPro]) in herpetic corneal graft failures.

METHODS

A series of 17 herpetic eyes of 14 patients with failed transplantations, treated with implantation of a corneal graft with a KPro, was reviewed. Outcomes measured were retention of the device, visual acuity at 1 week, best visual acuity, last assessed visual acuity, time of follow-up, and complications.

RESULTS

Follow-up ranged between 6 and 72 months (median, 14 months). All patients had improvement in postoperative visual acuity, with 16 (94%) of 17 eyes getting better than preoperative visual acuity within 1 week. Of the 17 eyes, 15 (88%) achieved a best visual acuity of 20/25 to 20/70 and, at the last examination, 11 eyes (73%) were still in that range. Four patients with prolonged preoperative inflammation and ulceration at KPro placement had resolution of inflammation within days. The KPro had no extrusions. Complications included retroprosthesis membrane in 3 eyes and 1 tissue melt in an early case.

CONCLUSIONS

The KPro can be of value in patients with graft failure from herpetic keratitis, even in the inflamed stage. We believe that herpetic keratitis is not a contraindication for KPro use.

HLA B27 scheint Transplantatversagen nach Hornhautverpflanzung bei herpetischen Hornhautnarben zu fördern

BACKGROUND

Herpes simplex virus (HSV) is the leading cause of infectious corneal blindness in the developed world. Eighty percent of the general population develop asymptomatic viral latency in the trigeminal ganglion following orofacial inoculation, but only 0.2% of all such orofacial inoculations are followed by recurrent corneal reactivation. Recurrences still threaten graft survival following penetrating keratoplasty, so that advance identification of patients at increased risk would be helpful in aftercare following penetrating keratoplasty. The HLA B27 phenotype is associated with increased susceptibility to genital HSV. However, no such association has been reported for herpetic eye disease.

METHODS

The HLA phenotypes of 129 patients who underwent penetrating keratoplasties for herpetic corneal scars were available for retrospective analysis. Four of these patients were positive for HLA-B27. The 125 HLA-B27-negative patients served as controls. The mean follow-up was 2.2 years. We compared the frequencies of herpetic recurrence and graft failure in the two groups using the Kaplan-Meier method and applied log-rank statistics.

RESULTS

After the average period of follow-up, 75% (three patients) of the HLA B27-positive patients experienced either graft failure or at least one reversible recurrence of the herpetic eye disease, as against only 25% of controls. This difference was highly statistically significant (p<0.01).

CONCLUSION

This retrospective analysis suggests that the HLA B27 phenotype promotes recurrence of herpetic eye disease following penetrating keratoplasty. HLA B27-positive patients should be closely monitored, and the indications for prophylactic antiviral therapy should be viewed liberally in this group.

On the influence of neutrophils in corneas with necrotizing HSV-1 keratitis following amniotic membrane transplantation

Necrotizing herpetic stromal keratitis (HSK) in mice rapidly improved after amniotic membrane transplantation (AMT). In this study we determined the fate of polymorphonuclear neutrophils (PMN) after AMT. AMT or tarsorrhaphy (T) was performed in BALB/c mice with ulcerative HSK. After 2 days, corneas were studied histologically and by transmission electron microscopy (TEM). CD11b, Gr-1, and TUNEL-positive cells were identified. Macrophages were depleted by subconjunctival injection of dichloromethylene-diphosphonate-liposomes (Cl(2)MDP-LIP) before AMT. Corneas were studied for interleukin (IL)-1alpha, IL-2, interferon (IFN)-gamma, CXCL1, CXCL2, and tumor necrosis factor (TNF)-alpha production by ELISA. PMN-enriched cell preparations co-cultured with amniotic membrane (AM) or with AM and such recombinant (r) cytokines as rIL-1alpha, rIL-2, and rTNF-alpha or supernatants from activated lymphocytes were investigated by flow cytometry (Annexin-V/7-AAD and TUNEL), and a dimethylthiazolyl-diphenyltetrazolium-bromide (MTT)-viability assay. Corneas in the AMT mice had less inflammation, fewer PMN-like cells and fewer CD11b+, and Gr-1+ cells (P<0.01), but a higher ratio of apoptotic to viable PMN-resembling cells (P<0.01) than the T mice. Phagocytic removal of apoptotic PMN-like cells by macrophages was evident in the AMT group. After Cl(2)MDP-LIP treatment, the corneas had more cell debris and apoptotic cells with PMN-like morphology. The concentrations of IL-1alpha, IL-2, CXCL1, and TNF-alpha were reduced in corneas of the AMT group as compared to that of the T group, while the concentration of CXCL2 was increased. Apoptosis of PMN-resembling cells was detected following cocultivation with AM, even when proinflammatory cytokines were present. Resolution of corneal inflammation in mice with necrotizing HSK after AMT is associated with increased apoptosis of PMN-like cells, reduction of pro-inflammatory cytokines, an increase of CXCL2, and increased removal of apoptotic PMN-like cells by macrophages.

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.

Amniotic membrane transplantation combined with antiviral and steroid therapy for herpes necrotizing stromal keratitis

PURPOSE

To evaluate therapeutic effect of multilayer amniotic membrane transplantation (AMT) in conjunction with antiviral and corticosteroid therapy on herpes necrotizing stromal keratitis.

DESIGN

Retrospective interventional case series.

PARTICIPANTS

Fifteen patients (15 eyes) with herpes necrotizing stromal keratitis, persistent corneal inflammation, and impending ulcer, despite topical and systemic antiviral treatment for over 2 weeks.

METHODS

Multilayer AMT was performed in the 15 eyes. Antiviral medications and appropriate corticosteroids were administered after surgery. Remodeling of amniotic membrane (AM) and growth of epithelial cells were detected by confocal microscopy.

MAIN OUTCOME MEASURES

Visual acuity and corneal status (ulceration, edema, and opacification).

RESULTS

Follow-up ranged from 7 to 13 months (mean +/- standard deviation, 8.9+/-1.8). Visual acuity improved by > or =2 lines in 14 eyes. Central corneal ulcers healed completely at 2.0+/-0.6 weeks, and paracentral ulcers at 2.1+/-0.6 weeks (t = 0.314, P = 0.759). Corneal stromal thickness was restored in eyes with central ulcers at 2.4+/-1.2 weeks and in those with paracentral ulcers at 2.6+/-0.7 weeks (t = 0.425, P = 0.678). Superficial epithelial cells, together with small basal epithelial cells, gradually migrated to the surface of AM on postoperative weeks 1 to 3. There were corneal nebulae in 11 eyes, corneal maculae in 3 eyes, and a corneal leukoma in 1 eye at the end of follow-up. No recrudescence occurred in any eye.

CONCLUSION

Multilayer AMT combined with antiviral and corticosteroid therapy appears effective in treating herpes necrotizing stromal keratitis. It provides patients with marked scars and visual impairment an opportunity for subsequent keratoplasty by arresting the inflammatory response and reducing the graft bed diameter.

Corneal buttons obtained from patients with HSK harbor high copy numbers of the HSV genome

PURPOSE

To detect herpes simplex virus (HSV) genome in the cornea, we sampled the limbal corneas and scleras of the imported eye bank eyes and recipient's corneal buttons and quantitated HSV genome in them by real-time polymerase chain reaction (PCR).

METHODS

Forty-four recipient corneas including 7 corneas with and 37 corneas without a history of herpetic keratitis, 70 eye bank donor limbal corneas, and 35 eye bank donor scleras were obtained. Primers for real-time PCR were synthesized using the HSV-1 and -2 common regions of the viral DNA polymerase. Primers for conventional PCR were designed to detect HSV-1 and -2 and varicella zoster virus (VZV).

RESULTS

Significantly higher copy number of HSV DNA was detected in corneas with a history of herpetic keratitis 85.7% (6/7), with an average of 1.6 x 10(4) copies/mg tissue weight than in corneas without a history of herpetic keratitis 10.8% (4/37), with an average of 8.7 copies/mg tissue weight (P < 0.05, Mann-Whitney U test). HSV DNA was detected in 5.7% (4/70) of the eye bank donor corneas, with an average of 4.9 x 10(2) copies/mg tissue weight, and in 8.6% (3/35) of the donor scleras, with an average of 10.6 copies/mg tissue weight. HSV-2 and VZV-DNA were not detected in these samples.

CONCLUSIONS

Real-time PCR quantitated HSV genome in the cornea even at a quiescent phase of infection. HSV genome was detected in the corneas and scleras without a past history of herpetic keratitis by this method.

Histology of Posterior Lamellar Keratoplasty

PURPOSE

To report histology of a posterior lamellar graft performed to treat clinically significant endothelial disease in a patient with Fuchs dystrophy.

METHODS

A 78-year-old patient with Fuchs dystrophy underwent posterior lamellar keratoplasty (PLK), the original form of endothelial keratoplasty performed with manual lamellar dissection of the recipient and donor corneas. Eighteen months later, the patient had herpes simplex virus keratitis and graft rejection episodes. One year after the infection resolved (2.5 years after PLK), penetrating keratoplasty was performed, and the excised corneal button was examined.

RESULTS

Histopathologic evaluation of the corneal button showed no discernible interface, opacity, or gapping between the anterior host stromal tissue and PLK donor tissue or any signs of significant migration of donor endothelial cells onto recipient tissue.

CONCLUSION

This PLK histology showed firm attachment with no visible interface between the posterior donor and anterior host stromal tissue. Surprisingly, no significant donor endothelial cell migration was detected on adjacent recipient tissue where Descemet membrane had been excised or where endothelial cells were lost as a result of the procedure.

Penetrating keratoplasty: outcomes from a corneal unit compared to national data

AIMS

To determine long term graft survival rates and visual results for different indications for penetrating keratoplasty from a single institution over 10 years and compare these to national outcome data.

METHODS

Retrospective chart analysis. 784 records were available for review of 1096 consecutive penetrating keratoplasty procedures performed between 1990 and 1999 (72%). Outcomes of graft survival, visual acuity, and astigmatism were analysed and compared to national outcome data supplied by the UK Transplant Service.

RESULTS

At 5 year follow up, overall graft survival was 66%. This was subdivided into 98% for keratoconus, 86% for viral keratitis, 85% for Fuchs' dystrophy, 84% for pseudophakic bullous keratopathy, 55% for regrafts, and 57% for other diagnoses. There was a significantly higher graft survival rate for all diagnostic subgroups except Fuchs' dystrophy at 3 years of follow up compared to the national average. Best corrected visual acuity at 5 years was 6/18 or better in 53% of cases. The mean keratometric astigmatism was 3.4 dioptres.

CONCLUSION

Penetrating keratoplasty is a safe and effective treatment for selected corneal disorders. Penetrating keratoplasty for viral keratitis may achieve good results with long term antiviral treatment. Patients may achieve better outcomes if their surgery is performed at specialist centres.

Comparative study of ocular herpes simplex virus in patients with and without self-reported atopy

PURPOSE

To compare the characteristics of ocular herpes simplex virus (HSV) in patients with and without atopy.

DESIGN

Retrospective cohort comparative study.

METHODS

Patients who presented at the Cornea Service, Wills Eye Hospital, between March 2003 and March 2004 who had been previously diagnosed in the same institution as having ocular HSV diagnosis or were just diagnosed as having the disease were asked to complete a study questionnaire that enabled categorization into atopic and nonatopic. In April 2005, 223 patients who agreed to be in the study had their charts reviewed, and 125 patients were excluded according to exclusion criteria: immunosuppression, follow-up less than one year, previous history of penetrating keratoplasty (PK) out of the Cornea Service, and no active HSV episode during follow-up.

MAIN OUTCOME MEASURES

Incidence of all types of HSV recurrences.

SECONDARY OUTCOME MEASURES

Bilaterality, visual loss, need for PK , and secondary bacterial infection in both groups. HSV episodes were classified into infectious, inflammatory, and mixed for analysis.

RESULTS

Ninety eight patients (110 eyes) were included in the study. Atopic/nonatopic (P value): the mean follow-up was 11.6 (+/- 10.6)/8.8 years (+/- 8.4) (P = .14); the mean incidence of HSV episodes per year of follow-up was: total episodes 0.32 (+/- 0.36)/0.28 (+/- 0.33) (P = .14), infectious 0.16 (+/- 0.22)/0.10 (+/- 0.14) (P < .01), inflammatory 0.11 (+/- 0.19)/0.11 (+/- 0.19) (P < .01), and mixed 0.09 (+/- 0.20)/0.07 (+/- 0.16) (P = .06); bilateral HSV was present in 9/3 patients (P = .22); the mean loss of vision was four lines of Snellen in both groups; PK was performed in 14 of 16 eyes (P = .45); secondary bacterial infection was present in two of four eyes (P = .26).

CONCLUSIONS

Atopic patients had considerably more infectious and fewer inflammatory episodes when compared with nonatopics.

[Multilayer amniotic membrane transplantation for treatment of necrotizing herpes simplex stromal keratitis]

OBJECTIVE

To evaluate the efficacy of multilayer amniotic membrane transplantation (AMT) combined with antivirus and corticosteroid drug to treat necrotizing herpes simplex stromal keratitis.

METHODS

Thirteen patients (13 eyes) of necrotizing stromal keratitis were referred to Shandong Eye Institute and Qingdao Eye Hospital between January 2003 and April 2004. The course of disease was 3 - 22 months (mean 15 months). Corneal inflammation persisted and corneal ulcer progressed despite topical and systemic antiviral treatment for over 1 weeks. Multilayer amniotic membrane transplantation was performed after excluding of bacterial and fungal infection by microbiologic studies including smears and cultures of necrotic corneal tissue and confocal microscope. Topical and systemic antiviral medications were given with adjuvant corticosteroid eyedrops postoperatively. We investigated the healing of corneal ulcer and improvement of stromal edema with slit lamp biomicroscope, the integrity of corneal defect with fluorescein staining, the migration of healthy corneal epithelial cells and transformation of amniotic membrane with confocal microscopy. All patients were followed up for 3 - 13 months (mean 10 months).

RESULTS

Corneal ulcer healed within 1 - 3 weeks postoperatively with negative fluorescein staining. Corneal stromal edema faded away within 1 month. Superficial amniotic membrane patches dissolved or shed on postoperative day 7 - 10, while the deeper grafts were adhered into the ulcer and fused with the surrounding fibroblasts. One of these grafts remained in situ more than 3 months. Confocal microscope examination indicated flat epithelial progenitor cells on the surface of residual amniotic membrane. Corneal transparence was achieved in 7 eyes, macula in 4 eyes and leucoma in 2 eyes 3 months after the operation. No recurrence of necrotizing stromal keratitis was occurred in 13 patients during the follow-up period.

CONCLUSION

Multilayer AMT combined with antivirus and corticosteroid treatment is an effective method to treat necrotizing herpes simplex stromal keratitis.

Transplantation of Amniotic Membrane in Murine Herpes Stromal Keratitis Modulates Matrix Metalloproteinases in the Cornea

PURPOSE

To study matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) in the corneas from mice with ulcerative herpes stromal keratitis (HSK) treated with amniotic membrane transplantation (AMT).

METHODS

The corneas from BALB/c mice were infected with HSV-1. Mice with ulcerative HSK on postinfection (PI) day 14 were used for the experiments. In one group of mice, the corneas were treated with transplantation of amniotic membrane (AMT) that was secured with a tarsorrhaphy, and a control group underwent tarsorrhaphy alone. After 2 days, the appearance of corneal ulcers and stromal inflammation was judged clinically. Corneal sections were studied by immunohistochemistry for the expression of MMP-2, -8, and -9 and TIMP-1 and -2. MMP activity in the corneas was investigated by zymography, and the expression of the enzymes was measured by the Western blot technique.

RESULTS

At day 14 PI, the ulcers stained intensely positive for MMP-2, -8, and -9 and TIMP-1 and -2. Ulceration (P < 0.001), stromal inflammation (P < 0.01) and inflammatory cell infiltration (P < 0.001) markedly improved by day 2 after AMT. This was associated with reduced expression (P < 0.01) and activity of MMP-8, and -9 and increased localization of TIMP-1 (P < 0.01), whereas TIMP-2 was not affected. In contrast, high levels of expression of MMP-8 and -9 remained in the cornea after tarsorrhaphy, and the TIMP-1 expression was only slightly upregulated.

CONCLUSIONS

Rapid improvement of HSV-1-induced ulcerative keratitis is noted after amniotic membrane transplantation. This may be caused by reduced expression and activity of MMP-8 and -9, increased expression of TIMP-1, and sustained expression of TIMP-2.

Infectious Keratitis After Astigmatic Keratotomy in Penetrating Keratoplasty

PURPOSE

To present 3 cases in 2 patients of infectious keratitis of the astigmatic keratotomy (AK) site in patients who had previous penetrating keratoplasty.

METHODS

History, clinical examination, chart review, cultures, and laboratory results were obtained from 2 patients with infectious keratitis within the donor stroma of their graft after an AK was performed.

RESULTS

One patient had an early infiltrate of the AK site that was culture negative. This cleared with fortified antibiotics, and the patient had a final visual acuity of 20/30-2. The second patient developed 2 late infections, the first with coagulase negative Staphylococcus and the second infection with Pseudomonas aeruginosa. Both of these infections cleared with fortified antibiotics, and the final visual acuity was 20/25. Neither patient developed a rejection episode from the infections, and both grafts survived.

CONCLUSIONS

We report a series of 3 cases of infectious keratitis in 2 patients after AKs in corneal grafts. This, to the best of our knowledge, has not been previously reported. Patients who suffer infectious keratitis after AK in corneal grafts may have good visual outcomes if managed with appropriate antibiotic regimens and closely followed.

Forty Years of Changing Indications in Penetrating Keratoplasty in Israel

PURPOSE

To examine the leading indications for keratoplasty and identify the changing trends in the past 40 years in Israel.

METHODS

Pathology reports of all penetrating keratoplasties (PKPs) performed at Hadassah-Hebrew University Hospital from 1961 to 2000 were reviewed. We evaluated the indications for keratoplasty in each decade between the years 1961 and 2000.

RESULTS

During the 40-year period, a total of 1681 PKPs were performed. Keratoconus (n = 478, 28.4%) was the most common indication, followed by graft failure (n = 226, 13.4%), pseudophakic corneal edema (PCE) (n = 142, 8.4%), herpetic infections (n = 125, 7.4%), nonherpetic infections (n = 114, 6.8%), scarring (n = 113, 6.7%), and trauma (n = 110, 6.5%). The 7 groups account for approximately 77.5% of all keratoplasties performed. Ocular infections were the most common indications before 1970 and have been declining ever since. Keratoconus became the leading indication in the past 30 years. In the past decade, of 663 keratoplasties, keratoconus was the most common indication (56, 38.6%) followed by graft failures/rejections and PCE (the second most common indication between the years 1981 and 1990).

CONCLUSIONS

Keratoconus was the leading indication for keratoplasty in our series. There was a decreasing trend in PK for ocular herpetic infections during the decades. The rate of PCE decreased while failed graft became the second most common indication for PKP during the past decade.

Epidemiology and molecular analysis of herpes simplex keratitis requiring primary penetrating keratoplasty

AIMS

To determine whether herpes simplex keratitis (HSK) has declined as an indication for penetrating keratoplasty (PKP) at the University of California San Francisco (UCSF) over the past 30 years.

METHODS

Records of the Hogan Eye Pathology Laboratory were reviewed to determine the incidence of PKP performed for HSK from 1972 through 2001. Archived corneal tissue with the diagnosis of HSK was evaluated for herpes simplex virus (HSV) DNA by polymerase chain reaction (PCR) based assays.

RESULTS

The number of corneal buttons submitted with the clinical diagnosis of HSK decreased from 1972 to 2001, while the overall number of PKPs performed did not. The percentage of corneal buttons with a clinical diagnosis of HSK that contained detectable HSV DNA did not change over the course of the study period.

CONCLUSION

HSK declined as an indication for PKP from 1972 to 2001 at UCSF. It is unlikely that this decline was the result of improved diagnostic accuracy since detection of HSV DNA in corneal buttons with a clinical diagnosis of HSK was similar at the beginning and end of the study period.

Bifokalfotographie mit dem HRA - eine optimierte Methode zur Beurteilung der Achslage torischer Intraokularlinsen

BACKGROUND

The assessment of axial orientation of toric IOLs (tIOLs) by monofocal photography can be deteriorated due to intrinsic errors e. g. globe rotation, head inclination or inadequate camera adaption and slide projection.

METHOD

In a 67 years old female a tIOL was implanted after penetrating keratoplasty for correction of high corneal astigmatism. A sequence of two fundus and two tIOL photographs (bifocal photography) was taken in a time interval of 3 months using the HRA II (Heidelberg Retina Angiograph II). A reference at the fundus was defined using two characteristic markers. The axial fundus orientation between the markers was overlaid to the line defined by the tIOL axis markers. The angular offset/distance between the fundus orientation line and the tIOL marker line was analyzed for each bifocal image at different time points.

RESULTS

The comparison of axial tIOL orientation between both different tIOL images revealed a rotation angle of 13 degrees (monofocal photograph). In contrast, using the bifocal photography and digital overlay technique the fundus line as a reference the tIOL rotated 1 degrees and 4 degrees from the first to the second time point of photography. Thus, the real rotation angle of tIOL measured only 3 degrees.

CONCLUSION

The bifocal photography with constant head position has the potential to minimize the intrinsic error in documentation of axial orientation of tIOL.

Penetrating keratoplasty: indications over a 10 year period

AIMS

To determine the indications for penetrating keratoplasty (PK) at the Corneoplastic Unit and Eye Bank, UK, a tertiary referral centre, over a 10 year period.

METHODS

Records of all patients who underwent PK at our institution between 1990 and 1999 were reviewed retrospectively. Of the 1096 procedures performed in this period, 784 records were available for evaluation (72%).

RESULTS

Regrafting was the most common indication, accounting for 40.9% of all cases. Keratoconus was the second most common indication (15%), followed by Fuchs' endothelial dystrophy (9.3%), pseudophakic bullous keratopathy (7.6%), and viral keratitis (5.9%), which included both herpes simplex and herpes zoster and showed a statistically significant decreasing trend using regression analysis (p<0.005). Among the regraft subgroup, viral keratitis accounted for 21.2% as the underlying primary diagnosis. The most common cause for graft failure in the regraft subgroup was endothelial failure (41.8%).

CONCLUSION

Regrafting is the leading indication for PK; viral disease-although declining-is the leading primary diagnosis.

[Amniotic membrane transplantation improves experimental herpetic keratitis. Modulation of matrix metalloproteinase-9]

PURPOSE

Transplantation of human amniotic membrane (AMT) accelerates the healing of experimental ulcerative herpetic keratitis. Here the expression and activity of matrix metalloproteinase (MMP)-9 was studied.

METHODS

BALB/c mice were corneally infected with HSV-1. Whereas the infected corneas of mice in group 1 were covered with AM, tarsorrhaphies were performed in others (group 2). After 2 days, the appearance of corneal ulcers and stromal inflammation was judged clinically, and the corneal PMN infiltration was studied histologically. The expression of MMP-9 in the corneas was localized by immunohistochemistry and analyzed by Western-blot technique. The MMP-9 activity in the corneas was determined by zymography.

RESULTS

On day 14, the ulcerating corneas had a dense PMN infiltration, the ulcers and the majority of PMNs were highly positive for MMP-9, and the active forms of MMP-9 were detected. Gelatinolytic activity was found in these corneas by zymography. Compared with the mice of group 2, ulceration, stromal inflammation and neovascularization markedly improved clinically and histologically within 2 days in mice of group 1. This was associated with a reduced expression of MMP-9 in corneal tissue and in PMNs. The gelatinolytic activity of MMP-9 was reduced after AMT.

CONCLUSIONS

These observations suggest that improvement of herpetic corneal ulcers and reduced corneal neovascularization after AMT may result from a reduced expression and activity of MMP-9.

Heparinbeschichtete Polymethylmethacrylat- und faltbare hydrophobe Acrylatintraokularlinsen bei Kataraktpatienten mit erworbenem Immundefektsyndrom und CMV-Retinitis

BACKGROUND

In HIV-positive patients with necrotising retinitis, well-tolerated lens material as well as minimal invasive surgery to avoid postoperative complications are imperative. Heparin surface-modified PMMA-IOLs as well as acrylic IOLs are associated with less postoperative inflammation than conventional intraocular lenses.

METHODS

In this randomised prospective clinical trial 18 patients received 7 HSM-IOLs through a self-sealing scleral tunnel and 11 foldable Acrysof-IOLs through a self-sealing limbal tunnel incision by the same surgeon. 7 of the 18 eyes were silicone oil-filled before cataract surgery, one eye received oil after the IOL implantation. Visual acuity, intraocular pressure, contrast sensitivity, intraocular inflammation and posterior capsule opacification were assessed. The follow-up period was 1 year.

RESULTS

Eyes with Acrysof-IOLs were associated with lower, but not statistically significant, laser flare photometry values (photon counts/ms) than those with HSM-IOLs pre- (90.18 +/- 54.7 vs. 73.92 +/- 6.44) and 3 months post-surgery (69.06 +/- 8.27 vs. 55.03 +/- 7.75). 6 of the 7 eyes with HSM-IOL and 3 eyes of the Acrysof-group developed a dense posterior capsule opacification (PCO), 2 eyes had no and 6 eyes only a distinct PCO. YAG capsulotomy did not improve visual acuity in any case but retinal examination was again possible. Eyes with Acryl-IOL showed pre- and postoperatively a better visual acuity than eyes with HSM-IOL ("hand movement" - 0.4 vs. "no light perception" - 0.1 pre- and 0.05 - 0.6 vs. "no light perception" - 0.1 3 months postoperatively. Contrast sensitivity testing (Vistech method) could be performed in the PMMA-group preoperatively only in 1 eye (A1), in the Acryl-group in 2 eyes (A4, B4, C2, D2) and revealed postoperatively "no contrast vision" - A1, B2, C1 vs. "no contrast vision" - A2, B2, C3, D1, E1. The intraocular pressure was preoperatively 13.86 mm Hg (PMMA) vs. 14.82 mm Hg (Acrysof) and 14.4 mm Hg vs. 12.89 mm Hg 3 months post surgery.

CONCLUSION

In the parameters we observed there was no statistical significant difference between heparin-surface modified (Pharmacia 811 C) and hydrophobic acrylic IOLs (Alcon Acrysof MA60BM) in patients with AIDS. As foldable Acrysof-IOLs can be implanted through a self-sealing bloodless tunnel incision and are associated with less posterior capsule opacification we prefer this IOL type in cataract surgery of AIDS patients.

Effect of oral acyclovir after penetrating keratoplasty for herpetic keratitis

OBJECTIVE

To determine the prophylactic effect of oral acyclovir on the recurrence rate of herpetic eye disease after penetrating keratoplasty.

DESIGN

A randomized, double-masked, placebo-controlled multicenter trial.

PARTICIPANTS

Sixty-eight consecutive patients (68 eyes) with corneal opacities due to herpetic eye disease who underwent penetrating keratoplasty.

INTERVENTION

Oral acyclovir 400 mg twice daily or placebo tablets for 6 months.

MAIN OUTCOME MEASURES

The recurrence rate of herpetic eye disease-related events and rejection episodes, proven by viral cell culture or polymerase chain reaction.

RESULTS

During the 2-year follow-up period, there were 3 culture-proven herpetic eye disease recurrences in the acyclovir group and 9 in the placebo group. Lifetime survival analysis of the probability of remaining free from recurrence revealed a significantly reduced risk of recurrent herpetic disease in the acyclovir-treated group.

CONCLUSION

This study suggests that oral acyclovir effectively prevents herpes-related recurrences after penetrating keratoplasty in herpetic eye disease.

Evaluation of hematoxylin and eosin and special stains for the detection of acanthamoeba keratitis in penetrating keratoplasties

PURPOSE

To compare the efficacy of a battery of routine and special histologic stains for the detection of acanthamoeba keratitis.

DESIGN

Observational study.

METHODS

Nine patients with culture-proven infectious keratitis whose clinical differential diagnosis included acanthamoeba and who had undergone penetrating keratoplasty were identified. Three cases each of culture-proven acanthamoeba, fungal, and herpes simplex keratitis were reviewed. Serial sections of the keratoplasty specimens were stained with hematoxylin and eosin, periodic acid-Schiff (PAS), Gomori methanamine silver (GMS), giemsa, Gram, calcofluor white, and acridine orange. Sections were reviewed in a random order and a masked fashion and classified as positive or negative for acanthamoeba, fungus, or herpes.

RESULTS

The correct diagnosis was made by examination of the hematoxylin and eosin stained slides in all cases. Correct diagnoses in decreasing order of frequency were made for slides stained with PAS, GMS, acridine orange, calcofluor white, giemsa, and Gram. There were false-positive diagnoses made only with calcofluor white and acridine orange stained slides because of staining of extracellular debris and other material.

CONCLUSIONS

When sections are examined by an experienced observer, hematoxylin and eosin is useful compared with calcofluor white, acridine orange, GMS, PAS, giemsa, and Gram stains for the detection of acanthamoeba keratitis.

Long-term results of penetrating keratoplasty. A 10-year-plus retrospective study

BACKGROUND

The aim of this study was to retrospectively analyse the outcome of a series of grafted patients over a period of more than 10 years and to determine their long-term survival probability.

METHODS

The records of 89 patients who had 103 grafts performed in 97 eyes were analysed. Mean follow-up was 12.8 years (range 10-17 years). Life table analysis (Kaplan-Meier) was used to evaluate the graft survival of the total population and of different groups.

RESULTS

Eighteen out of 89 patients (20.2%) had died. At the last visit before their death, 10 of the 21 grafts in those patients were still clear. Graft survival rates after 1, 2, 5 and 10 years were 79%, 73%, 59% and 50%; the rate at the end of follow-up was 47%. Survival rate at the end of the study was 94.7% for keratoconus, 57.1% herpes keratitis, 33.3% for pseudophakic keratopathies, 28.5% for post-traumatic keratopathies and 11.1% for re-grafts. In the group of patients grafted for aphakic or pseudophakic keratopathy, 40% died during the study. In 45% of cases their grafts were clear at the time of death. Endothelial decompensation and definitive graft rejection were the main causes of failure.

CONCLUSIONS

The outcome of keratoplasty is progressively getting worse with time in pseudophakic or traumatic keratopathies whereas survival rates are still stable from 10 to 17 years in grafts performed after keratoconus or herpetic keratitis.

[Amniotic membrane transplantation improves herpetic keratitis by local and not by systemic effects]

PURPOSE

The immune mediated HSV-1 stromal keratitis (HSK) rapidly improves after amniotic membrane transplantation (AMT). This study investigated whether AMT modulates the T cell response and whether the anti-inflammatory action of AMT is due to local or systemic effects.

METHODS

Corneas of BALB/c mice were infected with 10(5) (PFU) of HSV-1. Animals with ulcerating keratitis on day 14 post-infection were divided into 4 groups: group 1 ( n=12): right eye AMT;group 2 ( n=12): right eye tarsorrhaphy; group 3 ( n=8): right eye tarsorrhaphy, left eye AMT;group 4 ( n=8): both eyes tarsorrhaphy. The mice were examined for clinical signs of HSV keratitis after 2 days. Corneal sections were studied histologically and the inflammatory cell infiltration was studied by immunohistochemical staining. DTH response and the HSV-specific 3H-thymidin-uptake were compared between the groups.

RESULTS

Compared to group 2, ulceration and stromal inflammation was profoundly improved in group 1 ( p<0.01). The corneas in the AMT mice had fewer inflammatory cells, CD3+,CD4+ and CD8+ cells than the control mice ( p<0.01). There were no significant differences between groups 1 and 2 with respect to the delayed type hypersensitivity reaction (DTH response) and the HSV-specific 3H-thymidin uptake. AMT or tarsorrhaphy on the left eyes in groups 3 and 4 had no influence on the course of keratitis or the T cell response.

CONCLUSIONS

Ulcerating herpetic keratitis markedly improves after AMT. Our observations indicate that this is caused predominantly by local and not by systemic AMT-related effects.

[Analysis of 24 viral keratitis cases treated by corneal graft from 1998-2000]

PURPOSE

To determine the clinical character of patients with keratoplasty after viral keratitis and comparison of pre- and postoperative visual acuity.

MATERIAL AND METHODS

The study involved 24 patients treated using corneal graft after viral keratitis complications. Sex, age, permanent residence, duration of disease, previous pharmacological treatment, indications to corneal graft and postoperative functional results were evaluated.

RESULTS

In 24 cases 16 (66.7%) were males in age 38-75 years old. Eight (33.3%) of the 24 cases were females in age 12-78 years old. Visual acuity improvement after corneal graft was observed in 23 patients. There was no visual acuity improvement in one case with considerable degree of optic nerve lesion.

CONCLUSIONS

The results of these examinations showed, that keratoplasty after viral keratitis complications were more frequent in males, especially in 40-59 age range, professionally engaged. Statistical analysis of these cases showed good prognosis of visual acuity improvement after surgical treatment.

Outcomes of implantation of an artificial cornea, AlphaCor: effects of prior ocular herpes simplex infection

PURPOSE

To review outcomes of AlphaCor artificial cornea implantation in patients with and without a history of ocular herpes simplex virus (HSV) and to determine whether herpetic eye disease is an indication for AlphaCor surgery.

METHODS

Outcomes of the initial 40 implantations were reviewed and stratified by the presence of a history of ocular disease caused by HSV. Outcomes measures (complications, visual acuity gained) were compared.

RESULTS

Eight of the 40 AlphaCor implantations (20%) were in patients with a history of ocular HSV. Six of these eight patients (75%) developed melt-related complications after AlphaCor insertion. Half of the affected patients required removal of the AlphaCor and replacement with a donor corneal graft to restore ocular integrity. In comparison, only six of the 32 (18.8%) patients without HSV developed a melt after AlphaCor insertion. Patients with HSV with devices in situ exhibited a mean loss of 0.3 line of best-corrected visual acuity compared with the preoperative visual acuity, whereas patients without HSV exhibited a mean gain of 1.4 lines of best-corrected visual acuity.

CONCLUSIONS

The extensive lamellar corneal surgery involved in AlphaCor implantation may precipitate reactivation of latent HSV such that reactivation and resultant inflammation reduce device biointegration and facilitate melting of corneal stromal tissue anterior to the device. Although there may be some benefit from systemic antiviral medication, the current series is not large enough to demonstrate such a benefit, and melting can occur despite medication. The statistically significant difference in outcomes between recipients of AlphaCor with and without HSV is evidence that a history of HSV should be an exclusion factor for AlphaCor surgery.

[Corneal herpes: what's new?]

The prognosis of herpetic keratitis has been dramatically improved during the past years because of a better understanding of their physio-pathologic phenomenons, and mostly because of the use of very efficient antiviral drugs. Superficial keratitis are easily cured in most cases; deep stromal keratitis, that often require corticosteroid treatment, are more difficult to heal. Prophylactic treatment of the recurrences by oral antiviral drugs represents a promising new concept for herpetic keratitis.

[Histopathology of herpetic corneal endotheliitis - a case report]

BACKGROUND

Clinically, corneal endotheliitis is characterized by endothelial cell edema associated with immune precipitates. It is supposed to be triggered by a humoral or cellular immunologic reaction against antigens of the corneal endothelium. As yet, only few histopathologic studies of this disease have been performed.

PATIENT

A 42-years-old patient developed a complete corneal nebula with neovascularizations due to relapsing herpetic keratitis. He underwent perforating keratoplasty. The inflammatory infiltrate lining Descemet's membrane and the corneal endothelium consisted mostly of CD 45 R0-positive T-lymphocytes with only few neutrophils, macrophages and CD 20-positive B-lymphocytes. We could not demonstrate any viral particles in the removed corneal tissue by either electron microscopy or using antibodies against Herpes simplex type I or II.

CONCLUSIONS

Histologically, herpetic endotheliitis appears to correspond to corneal endotheliitis due to graft rejection. Complete virus particles are not necessarily required in case of long-standing inflammation and corneal neovascularizations.

The outcome of corneal grafting in patients with stromal keratitis of herpetic and non-herpetic origin

AIM

To evaluate the outcome of corneal grafting in patients with stromal keratitis of herpetic (HSK) and non-herpetic origin, using predefined diagnostic criteria and standardised postoperative therapeutic strategies.

METHODS

384 adult immunocompetent recipients of a corneal graft for herpetic (n = 186) or non-herpetic (n = 198) keratitis were followed up prospectively for up to 5 years.

RESULTS

The herpetic group displayed significantly more corneal vascularisation (p = 0.013), more epithelial defects (p = 0.049), lower corneal sensitivity (p <0.001), more graft rejection episodes (p = 0.002), and required larger grafts (p<0.001). However, the postoperative course of visual acuity, endothelial cell numerical density, and rate of graft failures were similar in both groups. After 5 years, cumulative probability of graft survival in HSK patients (40.85%) was similar to that observed in individuals with non-herpetic keratitis (50.15%; log rank = 0.874; relative risk: 1.04).

CONCLUSION

Despite a markedly higher preoperative risk profile in herpetic eyes, the functional outcomes of grafts in individuals with keratitis of herpetic or non-herpetic origin were similar. Probably the most important contribution is a consequent close follow up and a therapeutic strategy including systemic prophylaxis of viral recurrence and of graft rejection by well adopted local steroid therapy.

[Clinical study on surgical outcome of penetrating keratoplasty for herpetic leukoma]

PURPOSE

To evaluate prognostic factors, rejection, and recurrence of herpetic keratitis, in keratoplasty for herpetic leukoma.

SUBJECTS AND METHODS

We compared surgical outcome between patients who underwent keratoplasty for herpetic leukoma and those who received it for non-herpetic disorders. We compared the eyes of 24 patients in the herpetic group with 17 eyes of 20 patients with non-herpetic corneal disorders, i.e., the non-herpetic group.

RESULTS

The rejection rate was 45.8% for the herpetic group and 5.00% for the non-herpetic group, showing significant difference(p < 0.05). Transparent grafts were obtained for 75.0% of the herpetic group and 85.0% of the non-herpetic group, giving no significant difference. In the herpetic group, graft transparency in eyes with recurrences were 94.1%(p < 0.05). Graft rejection occurred mostly within 1 year postoperatively. RecuRrent herpetic keratitis tended to occur within 3 years and it was later than graft rejection.

CONCLUSION

In patients who underwent keratoplasty for herpetic leukoma, steroid therapy is important for 1 postoperative year to suppress graft rejection, but after that, steroid treatment should be carefully considered to minimize the risk of recurrences of herpetic keratitis.

Corneal endothelial cell changes twenty years after penetrating keratoplasty

PURPOSE

To evaluate retrospectively the corneal endothelium in 15 eyes which showed clear cornea for 20 years or longer after penetrating keratoplasty.

METHODS

The corneal endothelium was investigated in 15 eyes. The causative lesion had been keratoconus in 10 eyes and herpetic keratitis in 5 eyes. At the time of surgery, the patients were aged from 6 to 45 years, average 25.3 +/- 10.4 years. The endothelial cell density was measured 10 and 20 years after surgery by specular microscope. The relation between the rate of endothelial cell density loss and postoperative graft rejection, final visual acuity, causative corneal lesion, age of the patient, and age of the donor was evaluated.

RESULTS

The endothelial cell population per mm(2) averaged 998 +/- 343 ten years after surgery and 852 +/- 245 twenty years after surgery. The rate of endothelial cell density loss thus averaged 12.1% +/- 16.3% during the last 10 years. This rate was independent of postoperative graft rejection, final visual acuity, causative corneal lesion, age of the patient, or age of the donor.

CONCLUSIONS

The corneal endothelial cells become stabilized 10 years after surgery in cases where the grafts remain transparent 20 years after surgery.

Single and multilayer amniotic membrane transplantation for persistent corneal epithelial defect with and without stromal thinning and perforation

AIMS

To evaluate the efficacy of amniotic membrane transplantation (AMT) in persistent corneal epithelial defect with or without stromal thinning and corneal perforation.

METHODS

28 patients (28 eyes) with persistent corneal epithelial defect unresponsive to medical treatment were given preserved human amniotic membrane transplants. The patients were divided into three groups: group A, persistent corneal epithelial defect 10 eyes; group B, epithelial defect with stromal thinning 13 eyes; and group C, corneal perforation five eyes. AMT was performed using one layer in group A and multilayers in group B and C. The causes of persistent epithelial defect were neurotrophic keratopathy (24 eyes), limbal deficiency (six eyes), exposure keratopathy (four eyes), and Mooren's ulcer (one eye).

RESULTS

Success was noted in 82.1% (23/28 eyes) in all groups, with 80% (8/10 eyes), 84.6% (11/13 eyes), and 80% (4/5 eyes) in groups A, B, and C respectively, with a mean follow up of 10.9 months (1-30 months). The mean epithelialisation time after AMT was 2.1 weeks. The healing times of groups B and C are also significantly shorter than group A (p=0.017 and 0.018, respectively). Corneal stromal thickness was significantly increased in all cases in groups B and C (p=0.006). Those with corneal perforation in group C were completely healed by multilayer AMT. There was no difference in the epithelialisation time between successful cases treated by a single operation (17 eyes) or repeated operation (six eyes). Vision improved in 18.9% (8/28 eyes) and worsened as a result of cataract formation in 2.3% (1/28 eyes). Failure was noted in 17.9% (5/28 eyes), because of corneal infection (two eyes), neurotrophic keratopathy with and without limbal deficiency (two eyes), and intractable corneal perforation (one eye). No patient developed major immediate postoperative complications or graft rejection.

CONCLUSION

Amniotic membrane can successfully treat refractory corneal epithelial defect by promoting epithelial healing and thus prevent corneal perforation. It can be used as a treatment for corneal perforation by restoring corneal stromal thickness so that emergency penetrating keratoplasty can be avoided.

Amniotic membrane transplantation in infectious corneal ulcer

PURPOSE

To evaluate the efficacy of amniotic membrane transplantation in the management of treated infectious corneal ulcer in which inflammatory reactions were responsible for corneal damage.

METHOD

A prospective study of 21 consecutive eyes (21 patients) was performed. Sufficient antibacterial, antifungal, or antiviral agents were applied to eradicate causative organisms before permanent or temporary amniotic membrane transplantation, or a combination of the two in few patients. The amniotic membrane was soaked in antiinfective agents before transplantation in all cases.

RESULTS

After amniotic membrane transplantation, follow-up times ranged from 4 to 28 months (mean, 18 months). Clinical indications included Staphylococcus species (four cases), Pseudomonas species (five cases), Acanthamoeba species (three cases), fungus (two cases), and herpesvirus (seven cases). The corneal surface was healed successfully and recurrences of microbial infection were not noted in any case. Visual acuity was improved in cases that were nonscarring or after additional penetrating keratoplasty.

CONCLUSION

Amniotic membrane transplantation seems to be a useful adjunctive surgical procedure for the management of infectious corneal ulcer by promoting wound healing and reducing inflammation.