Viral Keratitis, Surgical Intervention in Viral Keratitis, Challenges in Diagnosis and Treatment of Viral Keratitis, HSV, HZV.

Viral keratitis is a significant cause of ocular morbidity and visual impairment worldwide. In recent years, there has been a growing understanding of the pathogenesis, clinical manifestations, and diagnostic modalities for viral keratitis. The most common viral pathogens associated with this condition are adenovirus, herpes simplex (HSV), and varicella-zoster virus (VZV). However, emerging viruses such as cytomegalovirus (CMV), Epstein-Barr virus (EBV), and Vaccinia virus can also cause keratitis. Non-surgical interventions are the mainstay of treatment for viral keratitis. Antiviral agents such as Acyclovir, Ganciclovir, and trifluridine have effectively reduced viral replication and improved clinical outcomes. Additionally, adjunctive measures such as lubrication, corticosteroids, and immunomodulatory agents have alleviated symptoms by reducing inflammation and facilitating tissue repair. Despite these conservative approaches, some cases of viral keratitis may progress to severe forms, leading to corneal scarring, thinning, or perforation. In such instances, surgical intervention becomes necessary to restore corneal integrity and visual function. This review article aims to provide an overview of the current perspectives and surgical interventions in managing viral keratitis. The choice of surgical technique depends on the extent and severity of corneal involvement. As highlighted in this article, on-going research and advancements in surgical interventions hold promise for further improving outcomes in patients with viral keratitis.

Initial High-Dose Prophylaxis and Extended Taper for Mushroom Keratoplasty in Vascularized Herpetic Scars.

PURPOSE: To report the outcomes of initial high-dose and extended taper of antiviral and steroid prophylaxis for the treatment of eyes with high-risk vascularized herpetic corneal scars that underwent 2-piece mushroom keratoplasty (MK). DESIGN: Prospective interventional case series. METHODS: In this single-center study, 52 consecutive eyes with vascularized (≥2 quadrants) herpetic corneal scars underwent 2-piece microkeratome-assisted MK. Initial high-dose and extended taper of combined oral and topical antiviral and steroid prophylaxis was administered. Outcome measures were best spectacle-corrected visual acuity (BSCVA), refractive astigmatism (RA), endothelial cell density, immunologic rejection, herpetic recurrence, and graft failure rates. RESULTS: Excluding patients with vision-impairing comorbidities, baseline BSCVA (1.73 ± 0.67 logMAR) significantly improved annually during the first 2 years (P < .001, P = .016), reaching 0.17 ± 0.18 logMAR at year 2, and remaining stable up to 10 years (P = .662). At 2 years, 86% of eyes saw ≥20/40, 55% saw ≥20/25, and 18% saw ≥20/20 Snellen BSCVA. RA exceeded 4.5 diopters in 7% of cases after wound revision for high-degree astigmatism in 7 cases. Endothelial cell loss was 40.9% at 1 year with an annual decline of 3.1% over 10 years. The 10-year cumulative risk for immunologic rejection, herpetic recurrence, and graft failure was 9.7%, 7.8%, and 7.6%, respectively. CONCLUSIONS: Initial high dose and extended taper of antiviral and steroid prophylaxis for MK in high-risk, vascularized herpetic corneal scars achieves clinical outcomes that remain stable for up to 10 years after surgery with minimal risk of immunologic rejection, herpetic recurrence and graft failure.

Conjunctival Epithelial Ingrowth After Penetrating Keratoplasty.

PURPOSE: To report a case of conjunctival epithelial ingrowth after penetrating keratoplasty. METHODS: A 57-year-old woman with herpetic corneal keratitis, endotheliitis, and bullous keratopathy underwent penetrating keratoplasty (PKP) and secondary cataract surgery. One month after cataract surgery, an epithelial ingrowth was observed at the 5 o'clock donor host junction. Ingrowth extended into the anterior chamber and along the iris surface by 9 months. Another PKP was performed, and the excised graft was submitted for histopathology. RESULTS: The graft showed CK13-positive and CK3-negative cells lining the endothelial surface, indicating the conjunctival origin of ingrown epithelium. Ten months postoperatively, no recurrence of ingrowth was observed. CONCLUSIONS: We experienced a rare case of conjunctival epithelial ingrowth after penetrating keratoplasty. There was no recurrence of the ingrowth after surgical removal, and the conjunctival origin may explain the relatively benign course of the complication.

Descemet Membrane Endothelial Keratoplasty in Irreversible Corneal Edema Due to Herpes Simplex Virus Endotheliitis.

PURPOSE: To report the clinical outcome and postoperative course of Descemet membrane endothelial keratoplasty (DMEK) in irreversible corneal edema due to herpes simplex virus (HSV) endotheliitis. METHODS: This is a retrospective, noncomparative, interventional case series. Nineteen eyes of 19 patients underwent standard DMEK combined with cataract surgery (triple DMEK) between May 2016 and April 2018. All patients received perioperative oral acyclovir (ACV) and prednisolone. Patients were followed up on day 1, on day 7, at 1 month, and then at 3 monthly intervals. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), graft clarity, pachymetry, and endothelial cell loss after 1 year were recorded. Postoperative complications and HSV recurrence were noted until the last follow-up visit. RESULTS: All eyes were phakic with variable grades of cataract with a preoperative BSCVA of 1.0 logarithm of the minimum angle of resolution or worse. The mean follow-up period was 19.3 ± 5.4 months. After 1 year, 14 (73.7%) eyes achieved a BSCVA of 0.3 or better. Seventeen (89.5%) patients had a clear graft at the last visit without any rejection episode. One graft failed after 16 months. After 3 months, the mean pachymetry reduced from 667.1 ± 62.1 to 512.8 ± 27.1 µm (P < 0.001). The mean endothelial cell loss after 1 year was 36.7 ± 13.4%. Three (15.8%) eyes had recurrence: one with recurrent endotheliitis and 2 with dendritic keratitis despite oral ACV, which responded to oral valacyclovir and ACV eye ointment. One patient had re-recurrence of endotheliitis after 20 months. CONCLUSIONS: DMEK in persistent corneal edema after HSV endotheliitis remains challenging but has encouraging outcomes. The postoperative course may be complicated by HSV recurrence. Prophylactic oral antivirals for 1 year or more and topical antivirals are useful for the prevention of recurrence.

The characteristics of Posner-Schlossman syndrome: A comparison in the surgical outcome between cytomegalovirus-positive and cytomegalovirus-negative patients.

This retrospective observational study aims to report the clinical characteristics and surgical results in eyes with Posner-Schlossman syndrome (PSS), and compare these outcomes between cytomegalovirus (CMV)-positive and -negative eyes.We reviewed the medical records of 21 consecutive immunocompetent patients clinically diagnosed with PSS between the years 2010 and 2018. Aqueous humor was collected from all the affected eyes to detect if CMV was present, and polymerase chain reaction (PCR) was performed using the herpesvirus family primers.The average period between the initial PSS attack and aqueous humor sampling at our institute was 9.3 years. Out of the 21 patients, 62% were CMV-positive. Regardless of CMV status, the mean intraocular pressure (IOP), mean deviation (MD), and central corneal endothelium cell (CEC) density, at the initial examination at our institute were already significantly worse in the affected eyes than in the unaffected eyes (all P values < .05). The average visual acuity (VA) was only significantly worse in the CMV-positive group (P = .02). Out of all the patients, those that were CMV-positive had undergone more glaucoma surgeries (P = .056). Fourteen patients underwent either a trabeculectomy (TRAB) or a trabeculotomy (LOT), and their IOP significantly reduced following surgery (P < .001). In 85.7% of those that had surgery, their IOP was successfully lowered to less than 20 mm Hg.Long-lasting PSS causes a decrease in VA, MD, and the CEC density. A prompt diagnosis is required, and an appropriate treatment plan should be formulated. In those patients with PSS that develop uncontrolled glaucoma, both TRAB and LOT may be effective in controlling IOP.

Descemet membrane endothelial keratoplasty for corneal decompensation caused by herpes simplex virus endotheliitis.

We report a case of corneal decompensation caused by recurrent herpetic endotheliitis that was treated successfully with Descemet membrane endothelial keratoplasty (DMEK). A 62-year-old woman presented with a history of recurrent herpetic infections in the right cornea. After topical and systemic treatment with antivirals and steroids for 5 months, DMEK combined with cataract surgery was performed. Two weeks after DMEK, the corrected distance visual acuity (CDVA) in the affected eye was 0.3 (20/60). One year postoperatively, the CDVA was 1.0 (20/20) and the slitlamp biomicroscopy showed no signs of graft rejection or herpetic recurrence. Corneal decompensation caused by herpetic endotheliitis used to be treated exclusively with penetrating keratoplasty. Descemet membrane endothelial keratoplasty combined with cataract surgery seems to be a favorable surgical option in the treatment of corneal endothelial decompensation after recurrent herpetic endotheliitis.

Long-term outcomes of the Boston type I keratoprosthesis in eyes with previous herpes simplex virus keratitis.

PURPOSE: To report the long-term outcomes of the Boston type I keratoprosthesis (Kpro) in eyes with prior herpes simplex virus (HSV) keratitis. METHODS: Retrospective review of all Kpro procedures performed by a single surgeon from 1 May 2004 to 1 January 2015. RESULTS: 13 of 173 Kpro procedures were performed in 11 eyes with prior HSV keratitis. There was not a significant difference in the percentage of eyes with and without prior HSV keratitis with preoperative (9% vs 8%, p=1.00) or postoperative (57% vs 60%, p=1.00) corrected distance visual acuity (CDVA) ≥20/200 or in the percentage of contralateral eyes with preoperative CDVA ≥20/50 (55% vs 30%, p=0.18). While several postoperative complications occurred approximately twice as often in eyes with prior HSV keratitis, including persistent epithelial defect (63.6% vs 34.1%; p=0.10), corneal infiltrate (27.3% vs 12.3%; p=0.17) and sterile vitritis (18.2% vs 9.4%; p=0.31), only cystoid macular oedema (45.5% vs 12.3%; p=0.01) was significantly more common. Similarly, while the Kpro retention failure rate in eyes with prior HSV keratitis was twice than that in eyes without it (0.15 vs 0.07 per year), the difference was not statistically significant (p=0.09). CONCLUSION: As greater than half of patients with unilateral HSV keratitis undergoing Kpro implantation have CDVA ≥20/50 in the contralateral eye, and as the Kpro retention failure rate in eyes with prior HSV keratitis is twice than that in eyes without prior HSV keratitis, caution should be exercised when considering Kpro implantation in these patients.

Changes in Higher-Order Aberrations After Phototherapeutic Keratectomy for Subepithelial Corneal Infiltrates After Epidemic Keratoconjunctivitis.

PURPOSE: To investigate how corneal aberrations change after phototherapeutic keratectomy (PTK) for subepithelial infiltrates after adenoviral keratoconjunctivitis. METHODS: The records of patients who underwent transepithelial PTK for subepithelial infiltrates were retrospectively reviewed. Preoperative best-corrected visual acuity (VA) and the results of slit-lamp biomicroscopy examinations were recorded. The PTK procedure was performed under topical anesthesia with an Amaris excimer laser. Patients' manifest refraction values, topographical examination results, and corneal aberrations before and after surgery were analyzed. RESULTS: Twenty-four eyes of 16 women (84.3%) and 3 men (15.7%) were treated. The mean follow-up time was 6.0 ± 2.5 (range: 3-12) months, and the mean ablation depth was 82.3 ± 1.0 (range: 80-88) µm. Postoperative median best-corrected VA increased from 0.6 (range: 0.4-1.0) logarithm of the minimum angle of resolution to 0.2 (range: 0.1-0.5) logarithm of the minimum angle of resolution (P = 0.048), coma decreased from 0.56 (range: 0.29-0.37) to 0.44 (range: 0.07-0.74), secondary astigmatism decreased from 0.45 (range: 0.12-1.9) to 0.17 (range: 0.03-0.49), and total higher-order aberrations decreased from 1.24 (range: 0.61-6.74) to 0.9 (range: 0.33-1.64) (P = 0.008, 0.0032, and 0.018, respectively). CONCLUSIONS: PTK is an effective method for treating corneal opacity after epidemic keratoconjunctivitis, which yields significant improvements in both VA and visual quality.

Case report: a diagnostically challenging conjunctival mass caused by the Epstein-Barr virus.

We present a paediatric case of infectious mononucleosis in a 13-year old, manifesting with follicular conjunctivitis and a conjunctival mass in one eye with no evidence of leucocytosis on the blood count. The diagnosis was confirmed following surgical excision and biopsy. The case represented a diagnostic challenge due to its atypism and given the steady increase in the prevalence of EBV-related ocular diseases in the last years, this report can serve as an example to prompt earlier serological tests to identify the aetiology in similar cases. This is important because EBV can be treated with acyclovir early in the active viral phase.

Successful corneal autograft after clearance of anterior chamber cytomegalovirus with oral valganciclovir in a patient with multiple failed corneal allografts.

PURPOSE: To report a case of recurrent corneal graft failure because of cytomegalovirus (CMV) infection and to demonstrate successful clearance of the virus with oral valganciclovir, confirmed by polymerase chain reaction (PCR) assay. This allowed for a successful corneal autograft to be performed. METHODS: Interventional case report. RESULTS: A 90-year-old white man with 4 previous corneal graft failures in his right eye is presented. His visual acuity was no light perception in the left eye subsequent to ocular trauma. His initial penetrating keratoplasty for pseudophakic bullous keratopathy was from a human leukocyte antigen-matched multiorgan donor who was CMV-seropositive. An anterior chamber paracentesis was performed to exclude an infective etiology. CMV was detected on PCR of aqueous humor. After a 12-week course of oral valganciclovir, a repeat aqueous PCR test confirmed the clearance of CMV. A corneal autograft from his left eye was subsequently performed with good outcome. CONCLUSIONS: We present a case of successful corneal autograft after clearance of CMV from the anterior chamber (PCR confirmed) in a patient treated with oral valganciclovir.

Isolated corneal papilloma-like lesion associated with human papilloma virus type 6.

PURPOSE: To report a case of a corneal papilloma-like lesion associated with human papilloma virus type 6. METHODS: A 48-year-old woman presented with a 2-year history of ocular discomfort and gradual visual deterioration in her right eye. Ophthalmic examination revealed an elevated, semitranslucent, well-defined vascularized mass approximately 4 × 2.5 mm in size localized to the right cornea. The surface of the mass appeared smooth and many small, shallow, and irregular elevations were noted. RESULTS: An excisional biopsy was performed. The underlying cornea was markedly thinned, and fine ramifying vasculature was also noted on the exposed corneal stroma. Typical koilocytic change was observed on the histopathologic examination. Polymerase chain reaction revealed the existence of human papilloma virus type 6 DNA. CONCLUSIONS: Here we describe a case of an isolated corneal papilloma-like lesion. Although the corneal extension of the limbal or the conjunctival papillomas has been commonly observed, an isolated corneal papilloma-like lesion with underlying stromal destruction has only rarely been reported.

Solitary giant molluscum contagiosum presenting as lid tumor in an immunocompetent child.

We report the case of a three-year-old male child who presented with a single painless subcutaneously located upper lid mass of 1.2 Chi 1.5 cm with a central depression. The mass could be easily separated from overlying skin on complete excision biopsy and showed a never described before whitish brain like appearance consisting of multiple lobes and gyri, which histopathologically proved to be molluscum contagiosum (MC). Tests to investigate underlying immunodeficiency did not show any evidence of immunocompromised state.

Major shifts in corneal transplantation procedures in north China: 5316 eyes over 12 years.

AIMS: To investigate the major shifts in the ratio of lamellar keratoplasty (LKP) to penetrating keratoplasty (PKP) and in the preoperative indications for each procedure. METHODS: Medical records of patients who received LKP and/or PKP at Shandong Eye Institute between 1996 and 2007 were categorised and reviewed. The time period was divided into intervals of 1996-8, 1999-2001, 2002-4 and 2005-7. RESULTS: A total of 4346 patients (5316 eyes) with integrated clinical records were included in the study. LKPs and PKPs were performed on 1558 eyes (29.3%) and 3758 eyes (70.7%), respectively. Within the first 3-year interval, the top three indications for LKP were chemical burns, keratoconus and corneal dermoid; the top reasons for PKP were viral keratitis, suppurative keratitis and corneal scarring. Within the last interval, suppurative keratitis, keratoconus and viral keratitis became most common indications for LKP and suppurative keratitis, viral keratitis and bullous keratopathy for PKP. The ratio of LKP to PKP operations tended to increase. CONCLUSION: Following proper indications, the use of LKP has increased in number in north China and has become particularly frequent in the management of corneal infections, keratoconus, corneal degeneration, and stromal dystrophy.

[Limbal transplantation: multicenter retrospective case series analysis]. / Estudio multicéntrico retrospectivo sobre trasplante de limbo.

PURPOSE: To report the results of limbal transplantation (LT) in patients with limbal stem cell deficiency (LSCD) in the context of ocular surface diseases. MATERIALS AND METHODS: A multicenter (5 centers) retrospective case series analysis of patients who underwent LT between 1996 and 2004 was performed. Data were collected by the same researcher using a customized database. Success was defined by the absence of a persistent corneal epithelial defect, on-going inflammation or recurrence of a pterygium. RESULTS: Data from 72 LT performed in 61 patients (65 eyes) with a mean follow-up of 20.8 months (SD 23.5; range, 3-115) were analyzed. There were 33 males and 28 females with a mean age of 55.8 years (SD: 15.6; range, 20-89). Fifty-eight (80.6%) LT were autografts (40 pterygia, 12 alkali burns, 3 iatrogenic cases, 2 viral infections, 1 neoplasia case) and 14 (19.4%) were allografts from cadaveric donors (7 immune-based disorders, 6 alkali burns, 1 iatrogenic case); all patients receiving allografts also received systemic immunosuppression. Of the total number of LT, 48 (66.7%) were successful. This proportion increased to 81.0% (47/58) when autografts were used. However, only 7.1% (1/14) of all allografts were successful. The success rate was higher (80.0%) when performed for a pterygium and lower when done for immune-based inflammation (14.3%). CONCLUSION: Autograft tissue for LT is always preferable to allografts to surgically treat LSCD, as clinical success is significantly higher, and systemic immunosuppression is avoided. As expected, immune-based disorders are the most difficult cases to treat. LT has been shown to be an excellent option for recurrent pterygium, although prospective studies need to be performed to further corroborate these results.

[Relationship between rubella virus and Fuchs heterochromic uveitis; 2 patients]. / Samenhang tussen rubellavirus en fuchs-heterochromie-uveïtis; 2 patiënten.

Two otherwise healthy men, aged 26 and 29 years, were diagnosed with Fuchs heterochromic uveitis (FHU) on the basis of the presence of iris heterochromia or iris atrophy, stellate corneal precipitates, and/or cataract. Microbiological investigation of aqueous humour demonstrated intraocular antibody production against rubella virus, but not against Toxoplasma gondii, herpes simplex virus or varicella zoster virus. Microbial nucleic acid detection was negative for all pathogens. Some time later, both patients underwent cataract surgery, which improved their vision considerably. FHU is a chronic, generally unilateral iridocyclitis, accompanied by the above-mentioned ophthalmologic manifestations in the absence of systemic disease. Little is known about the pathogenesis ofFHU, but recent publications have provided evidence for the possible involvement of the rubella virus.

Molluscum contagiosum in a patient with no risk factors.

PURPOSE: To report a case of molluscum contagiosum in a patient with no risk factors. METHODS: A 38-year-old patient with a tumor located in the lower eyelid that appeared 5 months previously was seen in the authors' hospital. The lesion had grown slowly and appeared as a crateriform mass with elevated edges. It was surgically excised and the histopathology study confirmed the diagnosis of molluscum contagiosum. Risk factors were absent. RESULTS: The histopathologic study confirms the presence of eosinophilic inclusion bodies in the keratinocytes cytoplasm. CONCLUSIONS: External evaluation of the lower lid lesion did not show the morphologic configuration of a molluscum contagiosum. A virus can be suspected if attention is paid to the margin of the eyelid and the patient's age.

Autologous cultivated conjunctival transplantation for recurrent viral papillomata.

PURPOSE: To describe the use of an autologous serum-free derived cultivated conjunctival epithelial equivalent in the treatment of extensive recurrent viral papillomata. DESIGN: Interventional case report. METHODS: A 10-year-old child with extensive recurrent viral papillomata involving the superior and inferior tarsal, forniceal, and bulbar conjunctiva underwent surgical excision of all diseased areas and double freeze-thaw cryotherapy. Autologous serum-free cultivated conjunctival equivalents were used to reconstruct the ocular surface and conjunctival fornices. RESULTS: Almost complete epithelialization was achieved within 5 days postoperatively. A good cosmetic and functional result was obtained, and no recurrences or cicatricial complications developed during 12-month follow-up. CONCLUSION: Transplantation of autologous cultivated conjunctiva was effectively used in the reconstruction of the ocular surface after extensive excision of recurrent viral papillomata. This modality of treatment may be useful in the treatment of ocular surface disorders in which extensive conjunctival and fornix reconstruction is required.