Journal List > J Korean Ophthalmol Soc > v.57(6) > 1010602

Kim, Yoo, Han, Chung, Seo, Yoo, Park, Cho, and Kim: Clinical Manifestations and Outcomes of Treatment in Cytomegalovirus Endotheliitis

Abstract

Purpose

To elucidate the clinical manifestations of cytomegalovirus (CMV) endotheliitis, and evaluate the outcomes of treatment in CMV endotheliitis.

Methods

We reviewed the medical records of 7 patients (8 eyes) who were diagnosed with CMV endotheliitis via a polymerase chain reaction (PCR) of aqueous humor and were treated with ganciclovir.

Results

Eight eyes of 7 patients were followed for a mean of 17.8 months. One patient had bilateral corneal endotheliitis. All eyes had coin-shaped keratoprecipitates and mild anterior chamber inflammation (1+∼2+). All eyes had an absence of anterior segment inflammation 3 weeks after ganciclovir treatment. Following treatment, the mean visual acuity improved significantly from 0.60 ± 0.40 (log MAR) at baseline to 0.18 ± 0.18 (log MAR) at last follow-up. The mean intraocular pressure (IOP) decreased significantly from 30 mm Hg at baseline to 12 mm Hg at last visit. Two eyes had a recurrence of corneal endotheliitis, where one underwent penetrating keratoplasty and the other was treated with intravitreal ganciclovir injection.

Conclusions

Patients with increased IOP and coin-shaped keratoprecipitates are suspected to have CMV endotheliitis, and PCR of aqueous humor is needed to diagnose CMV endotheliitis. More than 6 weeks of ganciclovir treatment might be effective for CMV endotheliitis and may help prevent recurrence.

References

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Figure 1.
Clinical photographs of patient 1. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in left eye of patient 1 (A, arrow). Specular microscopy revealed pleomorphism and polymegathism of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive in cytomegalovirus (CMV) (C). After withdrawal of valganciclovir, bullous keratopathy occurred (D). No recurrence had been occurred after penetrating keratoplasty (E). EBV = Epstein-Barr virus; HHV6 = human herpes virus 6; HSV1, 2= herpetic simplex virus 1, 2; VZV = varicella-zoster virus; IC = internal control; NC = negative control; PC = positive control.
jkos-57-863f1.tif
Figure 2.
Clinical photographs of patient 2. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in right eye (A, arrow) and left eye (B, arrow) of patient 2. Specular microscopy revealed decreased number, pleomorphism and polymegathism of corneal endothelial cells in right (C) and left eyes (D). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in both eyes (E). After valganciclovir treatment, keratic precipitates and edema of cornea were disappeared in right (F) and left eye (G). EBV = Epstein-Barr virus; HHV6 = human herpes virus 6; HSV 1, 2 = herpetic simplex virus 1, 2; VZV = Varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f2.tif
Figure 3.
Clinical photographs of patient 3. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in right eye (A, arrow) of patient 3. Specular microscopy revealed decreased number and polymegathism of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in right eye (C). Corneal lesions were disappeared after ganciclovir treatment (D). HHV6 = human herpes virus 6; EBV = Epstein-Barr virus; HSV1, 2 = herpetic simplex virus 1, 2; VZV = varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f3.tif
Figure 4.
Clinical photographs of patient 4. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in left eye (A, arrow) of patient 4. Specular microscopy revealed decreased number, polymegathism, pleomorphism, and hy-po-reflectivity of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in left eye (C). Two months after completion of ganciclovir treatment of 6 weeks, coin-shaped keratic precipitates were re-appeared in different location of cornea (D, arrows). Repeated multiplex polymerase chain reaction (PCR) revealed positive with CMV in aqueous humor (E). Corneal keratic precipitates and edema were regressed after intravitreal ganciclovir injection (F). HHV6 = human herpes virus 6; EBV = Epstein-Barr virus; HSV1, 2 = herpetic simplex virus 1, 2; VZV = Varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f4.tif
Figure 5.
Clinical photographs of patient 5. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in right eye (A, arrow) of patient 5. Specular microscopy revealed decreased number, polymegathism, and hypo-reflectivity of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in right eye (C). After ganciclovir treatment, coin-shaped keratic precipitate was regressed (D). HHV6 = human herpes virus 6; EBV = Epstein-Barr virus; HSV1, 2 = herpetic simplex virus 1, 2; VZV = Varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f5.tif
Figure 6.
Clinical photographs of patient 6. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in right eye at superior cornea (A, arrow) of patient 6. Specular microscopy revealed decreased number and polymegathism of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in right eye (C). Corneal lesions were disappeared after ganciclovir treatment (D). HHV6 = human herpes virus 6; EBV = Epstein-Barr virus; HSV1, 2 = herpetic simplex virus 1, 2; VZV = Varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f6.tif
Figure 7.
Clinical photographs of patinet 7. Slit lamp photograph showed sectorial corneal edema and coin-shaped keratic precipitates in left eye at inferior cornea (A, black and white arrow) of patient 7. Specular microscopy revealed decreased number of corneal endothelial cells (B). Multiplex polymerase chain reaction showed positive with cytomegalovirus (CMV) in aqueous humor in left eye (C). After ganciclovir treatment, lesions of cornea were vanished (D). HHV6 = human herpes virus 6; EBV = Epstein-Barr virus; HSV1, 2 = herpetic simplex virus 1, 2; VZV = Varicella-zoster virus; IC = internal control; PC = positive control; NC = negative control.
jkos-57-863f7.tif
Table 1.
Clinical data of patients with CMV endotheliitis
Pt. Sex Age (years) Baseline BCVA (log MAR) Baseline IOP (mm Hg) Baseline ECC (/mm3) Baseline CCT (μm) Coin-shaped KPs CMV IgM/IgG Previous ocular surgery Follow up (months)
1 M 50 0.69 24 614 739 Y −/+ 31
2 (OD) M 53 0.69 32 802 622 Y −/+ Trab 26
2 (OS) M 53 1.0 38 850 610 Y −/+ Trab, AGV 26
3 M 68 0.22 27 1,149 557 Y −/+ Trab 18
4 M 65 0.22 29 1,348 572 Y   18
5 M 52 1.0 26 923 583 Y −/+ 10
6 M 48 1.0 16 1,196 604 Y   Trab 10
7
M
48
0
48
1,758
602
Y
 

3
Mean   54.6 0.60 30 1,067 611.1       17.8

CMV = cytomegalovirus; BCVA = best corrected visual acuity; IOP = intraocular pressure; ECC = endothelial cell count; CCT = central corneal thickness; KP = keratic precipitate; MAR = minimal angle of resolution; Trab = trabeculectomy; AGV = ahmed glaucoma valve implantation.

Table 2.
Course of treatment in patients
Pt. Treatment Recur
1 Oral VGCV 1,800 mg 3 wks (d/t self stop) Y
  → post PKP: oral VGCV 1,800 mg 6 wks + 900 mg 6 wks  
2 (OD) Oral VGCV 1,800 mg 6 wks + 900 mg 6 wks N
2 (OS)   N
3 IV GCV 5 mg/kg 2 wks & oral VGCV 1,800 mg 4 wks + 900 mg 6 wks N
4 Oral VGCV 1,800 mg 3 wks + 900 mg 3 wks Y
  → Intravitreal GCV inj. (2 mg/0.1 mL)  
5 Oral VGCV 1,800 mg 3 wks + 900 mg 3 wks N
6 Oral VGCV 1,800 mg 3 wks + 900 mg 3 wks N
7 Oral VGCV 1,800 mg 3 wks + 900 mg 3 wks N

Recur = recurrence; VGCV = valganciclovir; wks = weeks; PKP = penetrating keratoplasty; GCV = ganciclovir; inj. = injection.

Table 3.
Changes of visual acuity and intraocular pressure
Pt. BCVA (log MAR)
IOP (mm Hg)
ECC (/mm3)
CCT (μm)
Baseline Final Baseline Final Baseline Final Baseline Final
1 0.69 0.30 24 12 614 1,092 739 528
2 (OD) 0.69 0.046 32 12 802 675 622 536
2 (OS) 1.0 0.15 38 15 850 793 610 520
3 0.22 0.046 27 12 1,149 1,164 557 505
4 0.22 0.10 29 15 1,348 1,443 572 525
5 1.0 0.52 26 15 923 826 583 524
6 1.0 0.30 16 5 1,092 1,196 604 520
7
0
0
48
10
1,758
1,750
602
531
Mean ± SD
0.60 ± 0.40
0.18 ± 0.18
30.0 ± 9.6
12.0 ± 3.4
1,067.0 ± 360.0
1,117.4 ± 358.8
611.1 ± 55.9
523.6 ± 9.3
p-value* 0.006 0.001 0.481 0.002

Values are presented as mean ± SD unless otherwise indicated.

BCVA = best corrected visual acuity; MAR = minimal angle of resolution; IOP = intraocular pressure; ECC = endothelial cell count; CCT = central corneal thickness.

* Paired-samples t-test.

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