title: Monitoring the inflammatory process in herpetic stromal keratitis: the role of in vivo confocal microscopy.
abstract: OBJECTIVE
  To investigate the role of in vivo confocal microscopy (IVCM) in the detection of inflammatory activity and follow-up of herpetic stromal keratitis (HSK).
  
  
  METHODS
  Prospective observational cohort study.
  
  
  METHODS
  Thirty-eight patients with active HSK.
  
  
  METHODS
  Within 7 days after diagnosis of active HSK, both eyes of each patient were examined by slit-lamp biomicroscopy and white-light IVCM (Confoscan 4; Nidek Technologies, Padova, Italy). The HSK-affected eyes were followed up at 1, 3, 6, and 12 months, whereas the unaffected fellow eyes were reexamined after 12 months. Three patients did not complete follow-up and were excluded for data analyses. All IVCM examinations were assessed for morphologic alterations characteristic of inflammatory activity and for corneal backscatter. As secondary outcome parameters, best-corrected visual activity (BCVA), central corneal thickness (CCT), intraocular pressure (IOP), and endothelial cell density (ECD) were determined at each study visit. We used repeated-measures analysis of variance to assess changes during the 12-month follow-up period and paired t tests to compare HSK-affected eyes with fellow eyes.
  
  
  METHODS
  Presence of dendriform cells, pseudoguttae, and keratic precipitates, and follow-up of mean corneal backscatter.
  
  
  RESULTS
  An increase of dendriform cells and pseudoguttae often accompanied stromal infiltration. Because these IVCM parameters were indiscernible or overlooked at slit-lamp examination, they proved to be excellent indicators of inflammatory activity. At 12 months' follow-up, mean corneal backscatter had decreased significantly by 36%, but still fell outside the normal range in 24 (69%) of the HSK-affected eyes. By using slit-lamp in conjunction with IVCM, we detected 17 recurrences in 14 of 35 patients (40%). Three of these recurrences were missed by slit-lamp, and 6 of these were missed by IVCM. At 12 months' follow-up, BCVA (-9 letters), CCT (-36 μm), and ECD (-313 cells/mm(2)) were significantly lower, whereas IOP (1.8 mmHg) was significantly higher, in HSK-affected eyes compared with fellow eyes.
  
  
  CONCLUSIONS
  The data presented demonstrate that IVCM is complementary to slit-lamp examination in the follow-up of HSK, particularly because of its power to detect early signs of intracorneal inflammatory activity. Therapy guidance based on morphologic assessment and corneal backscatter measurement by combined IVCM and slit-lamp examination may improve the outcome of HSK.
  
  
  BACKGROUND
  The author(s) have no proprietary or commercial interest in any materials discussed in this article.
authors.affiliation: Rotterdam Ophthalmic Institute, Rotterdam, The Netherlands. t.hillenaar@oogziekenhuis.nl
authors.forename: Toine
authors.initials: T
authors.lastname: Hillenaar
authors.forename: Hugo
authors.initials: H
authors.lastname: van Cleynenbreugel
authors.forename: Georges M G M
authors.initials: GM
authors.lastname: Verjans
authors.forename: René J
authors.initials: RJ
authors.lastname: Wubbels
authors.forename: Lies
authors.initials: L
authors.lastname: Remeijer
mesh_terms: D000212:Acyclovir / Q000627:therapeutic use; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000998:Antiviral Agents / Q000627:therapeutic use; D002452:Cell Count; D003319:Corneal Stroma / Q000473:pathology* / Q000821:virology; D003907:Dexamethasone / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D004728:Endothelium, Corneal / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000627:therapeutic use; D018259:Herpesvirus 1, Human / Q000302:isolation & purification; D014645:Herpesvirus 3, Human / Q000302:isolation & purification; D006801:Humans; D007249:Inflammation / Q000175:diagnosis; D007429:Intraocular Pressure; D016849:Keratitis, Herpetic / Q000175:diagnosis* / Q000188:drug therapy / Q000821:virology; D008297:Male; D018613:Microscopy, Confocal; D008875:Middle Aged; D011446:Prospective Studies; D014792:Visual Acuity / Q000502:physiology; D055815:Young Adult
chemical_list: D000998:Antiviral Agents; D005938:Glucocorticoids; D003907:Dexamethasone; D000212:Acyclovir