Oral acyclovir after penetrating keratoplasty for herpes simplex keratitis.

OBJECTIVE: To determine the efficacy of systemic acyclovir in decreasing complications and improving the outcome of penetrating keratoplasty for herpes simplex virus (HSV) keratitis. METHODS: Retrospective study of 53 primary penetrating keratoplasties for HSV keratitis at an eye hospital from January 1, 1989, through December 31, 1996. Medical records were analyzed for history of HSV keratitis, preoperative neovascularization, and disease activity. Postoperative use of acyclovir, recurrence of HSV keratitis, rejection, uveitis or edema, and graft failure were evaluated. RESULTS: Twenty-four patients (mean +/- SD follow-up, 44.7 +/- 32.6 months) received no acyclovir and were compared with 20 patients, (mean +/- SD follow-up, 28.8 +/- 16.7 months), who received 400 mg acyclovir twice a day for at least 1 year. No patient in the acyclovir group had a recurrence of dendritic keratitis in the first year compared with 5 (21%) of the patients who did not receive acyclovir (P = .03). No patient had graft failure in the acyclovir group compared with 4 (17%) in the group without acyclovir after 1 year of follow-up (P = .06). CONCLUSION: Postoperative systemic acyclovir therapy after penetrating keratoplasty for HSV keratitis is associated with a reduced rate of recurrent HSV dendritic keratitis and possible graft failure at 1 year of follow-up.

Efficient reactivation of latent herpes simplex virus type 1 infection by excimer laser keratectomy in the experimental rabbit ocular model.

PURPOSE: To investigate the role of excimer laser keratectomy as a trigger for the reactivation of latent HSV type 1 (HSV-1) in the New Zealand rabbit ocular model. There are conflicting reports in the current literature about reactivation of HSV-1 after excimer laser photoablation. METHODS: New Zealand rabbits were inoculated topically with HSV-1 McKrae or W strain in each eye, and culture-positive dendritic keratitis was documented on day 7. After the establishment of latency (21+ days), animals were divided into three groups: group I animals underwent excimer laser photoablation in each eye; group II animals received intrastromal injections of sterile water to act as positive controls (a standard method); and group III animals received no treatment and represented spontaneous shedders. All eyes were swabbed daily from days 1 through 10 and plated on A549 cells. Recovery of HSV-1 on days 1 through 10 postinduction was analyzed to compare the efficiency of the different methods of viral reactivation. RESULTS: Reactivation of latent HSV-1 after excimer treatment was observed in nine (45%) of 20 eyes and was equivalent to the rate of reactivation seen in the positive control animals (eight [44.4%] of 18 eyes) (P=.99). Both of these rates were significantly greater than those of the untreated animals (one [5.6%] of 18 eyes) (P=.018). CONCLUSION: Excimer laser keratectomy appears to be an efficient trigger for the reactivation of latent HSV-1 in the New Zealand rabbit ocular model.

The use of conjunctival flaps in the treatment of herpes keratouveitis.

Conjunctival flaps have been used in the treatment of corneal diseases since the 1800s, although in recent years their use has decreased. In selected cases, however, the placement of a conjunctival flap still may be the treatment of choice. We report our experience with the use of conjunctival flaps in patients with herpes keratouveitis who had persistent corneal epithelial defects. Preoperatively, all patients had chronic or recurrent epithelial defects and intraocular inflammation with or without recurrent live viral infection requiring frequent medicine application and office visits. Postoperatively, all patients had an intact, healthy ocular surface and a noninflamed eye requiring few to no medications and infrequent office visits. No patient has had recurrent live viral activity.

Corneal transplantation in infants, children and young adults: experience of the Toronto Hospital for Sick Children, 1979-88.

Between 1979 and 1988, 85 penetrating keratoplasty procedures were performed in 54 patients aged 1 month to 18.2 years at the Hospital for Sick Children, Toronto. The minimum length of follow-up was 3 months. A clear transplant was obtained in 27 eyes: 7 of 16 eyes with Peter's anomaly, 0 of 8 eyes with congenital glaucoma, 2 of 5 eyes with herpes simplex keratitis, 6 of 8 eyes with corneal dystrophy and 12 of 17 eyes with traumatic corneal scars. The most recent visual acuity was best in the trauma and dystrophy groups and worst in the congenital glaucoma group. Visual acuity results were better in older children and were fair in younger children and those with postoperative complications. Although penetrating keratoplasty is more difficult in children than in adults, it has a reasonable chance of success. However, the poor outcome in the congenital glaucoma group indicates that the procedure is not warranted in such patients.

Indications for penetrating keratoplasty: 1980-1988.

A retrospective analysis was undertaken of the clinical diagnoses of 1594 eyes that underwent penetrating keratoplasty performed in a private-referral corneal practice over a 9-year period, 1980-1988. The seven most common indications for surgery were keratoconus (24.0%), pseudophakic or aphakic bullous keratopathy (21.2%), corneal scarring (13.9%), Fuchs' endothelial dystrophy (12.5%), regraft (8.1%), and herpetic keratitis (5.3%). Keratoconus was the leading indication from 1980 to 1985. From 1985 to 1988, pseudophakic bullous keratopathy became the leading indication and correlates well with known complications associated with closed-loop anterior chamber lenses, which were widely used during the early 1980s. Less frequent indications for penetrating keratoplasty included the following: infectious (nonviral) keratitis (3.5%); acute or chronic ulcerative keratitis (2.7%); interstitial keratitis (1.8%); mechanical trauma (1.5%); other (non-Fuchs') corneal dystrophies (1.4%); congenital opacities (0.8%); and chemical burns (0.5%).

Recurrent herpes simplex keratitis with concurrent epithelial and stromal involvement. Immunohistochemical and ultrastructural observations.

A 65-year-old man with recurrent herpetic keratitis underwent corneal transplantation for persistent nonimmunologic graft failure. Histopathologic examination of the corneal button revealed an epithelial dendrite containing Cowdry type A inclusion bodies, moderate stromal edema, and a retrocorneal fibrous membrane. Immunohistochemical studies demonstrated herpes simplex virus antigens in epithelial cells bordering the dendritic defect and in stromal keratocytes. The mean width of corneal epithelium displaying herpes simplex virus-positive epithelial cells on either side of the dendritic defect measured 200 +/- 46 microns. By electron microscopy, herpesvirus particles were identified in epithelial cells lining the dendrite as well as in stromal keratocytes. Infected keratocytes were scattered throughout the stroma but were not observed subjacent to the epithelial dendrite. This study demonstrates that a recurrent epithelial dendrite can be associated with subclinical stromal infection of the graft.

Medical manpower requirements following penetrating keratoplasty for herpes simplex keratitis.

We have compared the post-operative course of patients requiring penetrating keratoplasty for herpes simplex virus keratitis, keratoconus, and Fuchs' endothelial dystrophy with a minimum of two years follow-up. Although some expected differences (age, sex) were found between these three groups, the number of post-operative clinic visits was not different between the three groups. This is contrary to the common belief that patients requiring penetrating keratoplasty for herpes simplex keratitis are high risk, and will make greater demands on medical resources in the post-operative period. The management of our patients with herpes simplex keratitis is not statistically different from a similar group managed at another centre.

Is raised intraocular pressure a bad prognostic sign in acute corneal graft rejection?

One hundred and forty acute corneal rejection episodes in 94 patients were studied retrospectively. Sixteen episodes in 15 eyes were associated with raised intraocular pressure (IOP) on admission, three of whom had had previously elevated IOP. At six weeks, six (37.5%) still required hypotensive therapy. Five eyes with raised IOP at rejection had lost vision at six weeks. Five of the six eyes with graft failure at review had raised IOP either pre-graft, at rejection or at follow-up. Eyes grafted for herpes simplex keratitis with hypertensive rejection episodes had a higher mean admission IOP, with a more short-lived rise than other eyes.

[Use of fresh amnion in the treatment of corneal diseases]. / Primenenie svezhego amniona v lechenii zabolevanii rogovitsy.

The effects of fresh amnion on the course of morbid processes in corneal ulcers and burn disease of the anterior segment of the eye were investigated. The cornea was coated with amnion in 15 eyes with deep bacterial ulcers, in 10 eyes with herpetic ulcers of the cornea, and in 8 eyes with second and third-degree corneal and conjunctival burns. The amnion was obtained in cesarean section and fixed to the limbal conjunctiva with an uninterrupted suture all around. The next day after surgery the pain syndrome reduced, as did photophobia and blepharospasm in all the patients. In the group of patients with bacterial ulcers the cornea epithelialized on days 5-11, in those with herpetic ulcers on days 10-15, and in those with burns on days 8-12 after amnion coating. No cases with suppuration of the burnt surface when coated with the amnion were recorded. The amnion slid off the cornea on days 7-10 after it was layered on.

[Microdiathermocoagulation in the treatment of herpetic keratitis]. / Mikrodiatermokoaguliatsiia v lechenii gerpeticheskogo keratita.

The authors analyze the efficacy of microdiathermocoagulation (MDC) in 126 patients with herpetic keratitis. Combined use of MDC and soft contact highly hydrophilic lenses preimpregnated with poludan, an interferon inductor solution, has helped reduce almost twofold the mean period of treatment of 80 patients with dendritic keratitis as compared to idoxuridine monotherapy. The study has shown the advantages of a soft contact lens over ointment dressing prescribed after such microsurgical manipulations to patients with superficial herpetic keratitis. A special microelectrode scarifier is suggested. The efficacy of MDC in the treatment of herpetic stromal keratitis with ulceration has been demonstrated, as well as in the management of superinfection manifestations (purulent ulcer, abscess of the cornea). The technique and the results of MDC are discussed and compared to mechanical abrasion and argon laser coagulation in herpetic keratitis.

The success and survival of repeat corneal grafts.

The results of 99 second grafts in individual eyes are reported. The five-year survival of these grafts was 49%. Allograft rejection was responsible for the majority of failures, but recurrence of host disease and endothelial decompensation were also important. Glaucoma was an important complication in 38% of eyes. Only 12 eyes in the series had no significant complication and 18 eyes achieved a corrected visual acuity of 6/12 or better.

The changing management and improved prognosis for corneal grafting in herpes simplex keratitis.

Graft survival in a previously reported cohort of patients recruited between 1967 and 1978 (10.6 years' mean follow-up) was reviewed and compared with that for a cohort recruited between 1979 and 1987 (3.8 years' mean follow-up). This allowed analysis of improved graft survival due to changes in management, introduced after critical review of the first group in 1978. The salient changes included transition from intracapsular to extracapsular cataract surgery (P = 0.001) and treatment of rejection episodes with antiviral prophylaxis. Extracapsular cataract surgery improved graft survival (P = 0.07) benefiting inflamed eyes which more frequently required concomitant surgery (P = 0.005). Survival of rejection episodes was improved by antiviral prophylaxis (P = 0.02), and the incidence of recurrent keratitis was reduced (P = 0.0005). The complete and prompt removal of loose sutures improved graft survival (P = 0.025). Long-term survival of first grafts was 70%, and management changes improved overall survival (P = 0.036) despite an increased number of eyes (P = 0.05) grafted when inflamed.

Clinical indications for and procedures associated with penetrating keratoplasty, 1983-1988.

We reviewed the preoperative clinical indications and associated surgical procedures for 2,299 penetrating keratoplasties performed at our institution from 1983 through 1988. Pseudophakic bullous keratopathy was the most common indication overall, accounting for 526 cases (23%). A marked increase was noted in the incidence of pseudophakic bullous keratopathy as an indication for penetrating keratoplasty beginning in 1985. The association of anterior chamber intraocular lenses in eyes with pseudophakic bullous keratopathy undergoing penetrating keratoplasty increased from 19 of 43 cases (44%) in 1983 to 79 of 108 cases (73%) in 1988. The incidence of intraocular lens exchange at the time of penetrating keratoplasty in cases of pseudophakic bullous keratopathy increased from six of 43 (14%) in 1983 to 63 of 108 (58%) in 1988. Other major indications for penetrating keratoplasty included Fuchs' dystrophy (375 cases, 16%), keratoconus (348 cases, 15%), aphakic bullous keratopathy (331 cases, 14%), and regraft (233 cases, 10%). Cataract extraction, with or without intraocular lens implantation, was combined with penetrating keratoplasty in 397 of 1,532 phakic eyes (26%). The incidence of triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens implantation) increased from 27 of 248 phakic eyes (11%) in 1983 to 68 of 258 phakic eyes (26%) in 1988.

Visual results after corneal transplantation.

The results of corneal transplantation can be measured by the percentage of clear grafts and by the subsequent visual acuity. In this study we summarized the visual results in five corneal diseases with a low rate of graft failure. Keratoconus patients achieved an average visual acuity of 0.5 one year after transplantation, while patients with corneal decompensation after previous cataract operation only reached an average of 0.2. Sometimes visual results were hampered by clouding of the graft and the reason for clouding was analysed in such cases. Reversible and irreversible rejections occurred with the highest frequency immediately after transplantation, and while in primary grafts 60% of rejections was reversible, only two out of ten repeat transplants could be saved. This indicates that more measures are necessary to prevent failure of secondary transplants in order to obtain the goal of useful vision.

[Keratoplasty à chaud: preliminary study]. / Kératoplasties à chaud: étude préliminaire.

The purpose of this paper is to review causes and follow up of 16 patients who have had a keratoplasty "à chaud" for corneal ulceration, perforation, or reviving chronically abscess, with a 9 years follow-up for a first group, and 8 months for the second. In 58%, the graft remained clear, and in 16%, the acuity was 4 to 6/10 degrees. Keratoplasty "à chaud" seems to be the most efficient method for treatment of inflammation, the most radical to restore the integrity of the eye, and can give oftentimes an accurate optical result.

[Cryoimmunotherapy of herpetic and metaherpetic keratitis]. / Kryoimunoterapie herpetické a metaherpetické keratitidy.

In 11 patients with relapsing herpetic keratitis and metaherpetic ulcers cryoimmunotherapy, as recommended by Amoils, was applied. Under instillation anaesthesia three cryocycles were made using a temperature of -80 degrees on the entire area of the lesion with subsequent instillation of 60 drops (1 drop per minute) of serum obtained from 15 ml of the patient's blood mixed with 5 ml gamma globulin. In all 11 patients progression of the disease was arrested, though it could not be checked by previous conservative therapy. The cornea cleared and vision improved. The method is effective, simple and expands therapeutic procedures which can be used in these tiresome conditions.

Ocular herpes simplex infection: pathogenesis and current therapy.

Ocular herpes simplex disease has a variable pattern of manifestations and recurrences as a result of the site and extent of the infection, the host immunologic events, the trophic damage within ocular tissues, and the toxic effects of antiviral medications. Laboratory research has established a clinical model and a working hypothesis about the complex pathophysiologic features of the disease and the interaction of the virus with its host tissue. Recent studies have further defined the viral genome and its role in virulence and pathogenicity. Antiviral therapy is effective in some but not all aspects of the ocular infection. A proposed clinical classification of ocular herpes simplex is based on the manifestations associated with viral disease and those associated with the host response and the subsequent structural damage. A plan for medical and surgical management of ocular herpes simplex, based on current knowledge of the disease process, relates to the integrity of the epithelium and the presence of active viral disease.