Cytomegalovirus endotheliitis in Descemet's stripping endothelial keratoplasty.
OBJECTIVE
To report 4 cases of undiagnosed cytomegalovirus (CMV) endotheliitis in patients who underwent Descemet's stripping automated endothelial keratoplasty (DSAEK).


METHODS
Retrospective interventional case series.


METHODS
Four eyes of 4 patients diagnosed with active CMV endotheliitis after DSAEK.


METHODS
Retrospective review of the medical records of 4 patients with DSAEK who had an aqueous tap that was positive for CMV DNA but negative for herpes simplex virus (HSV) and varicella zoster virus.


METHODS
Clinical features and management.


RESULTS
Four immunocompetent Chinese male patients with a mean age of 67 years underwent DSAEK for posterior polymorphous dystrophy (1), Fuchs' heterochromic cyclitis (1), pseudophakic bullous keratopathy (1), and herpetic keratouveitis (1). Clinical findings seen in all patients were localized corneal edema, increased intraocular pressure, pigmented keratic precipitates (KPs), and no/minimal anterior chamber (AC) activity. An unexplained sudden decrease in endothelial cell count (ECC) in the absence of rejection or significant inflammation was seen in 3 patients, whereas 1 patient also developed concomitant retinitis. CMV DNA was positive in all aqueous specimens and from the vitreous of the patient with retinitis. All patients were treated with oral valganciclovir with resolution of inflammation; 2 patients had recurrences; 1 patient developed recurrent retinitis; and 1 patient developed recurrent CMV endotheliitis and is currently receiving maintenance therapy with oral valganciclovir.


CONCLUSIONS
CMV endotheliitis with corneal edema masqueraded as a variety of other endothelial conditions, which resulted in DSAEK surgery being performed in these patients who may have responded to antiviral treatment without the need for endothelial transplantation. A heightened awareness is required to exclude CMV endotheliitis as the cause for endothelial decompensation or unexplained, sudden reduction in ECCs post-DSAEK in the absence of other complications, and it should be differentiated from allograft rejection in view of the critical difference in treatment.
Anshu
Arundhati
A
Singapore National Eye Center, Singapore.
Chee
Soon-Phaik
SP
Mehta
Jodhbir S
JS
Tan
Donald T H
DT
D000368:Aged; D000369:Aged, 80 and over; D000998:Antiviral Agents / Q000627:therapeutic use; D001082:Aqueous Humor / Q000821:virology; D002452:Cell Count; D003317:Corneal Dystrophies, Hereditary / Q000601:surgery; D015715:Corneal Edema / Q000175:diagnosis / Q000188:drug therapy / Q000821:virology; D016039:Corneal Transplantation / Q000379:methods*; D003587:Cytomegalovirus / Q000235:genetics / Q000302:isolation & purification; D003586:Cytomegalovirus Infections / Q000175:diagnosis / Q000188:drug therapy / Q000821:virology*; D017726:Cytomegalovirus Retinitis / Q000175:diagnosis / Q000188:drug therapy / Q000821:virology; D004279:DNA, Viral / Q000032:analysis; D003886:Descemet Membrane / Q000601:surgery*; D004728:Endothelium, Corneal / Q000473:pathology / Q000637:transplantation* / Q000821:virology*; D015828:Eye Infections, Viral / Q000175:diagnosis / Q000188:drug therapy / Q000821:virology*; D015774:Ganciclovir / Q000031:analogs & derivatives / Q000627:therapeutic use; D006801:Humans; D007634:Keratitis / Q000175:diagnosis / Q000188:drug therapy / Q000821:virology*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D000077562:Valganciclovir; D014792:Visual Acuity
D000998:Antiviral Agents; D004279:DNA, Viral; D000077562:Valganciclovir; D015774:Ganciclovir