Journal List > J Korean Ophthalmol Soc > v.57(6) > 1010621

Kim, Lim, and Kim: A Case of Cytomegalovirus Corneal Endotheliitis Almost Misdiagnosed as Corneal Graft Rejection



To report a case of cytomegalovirus (CMV) corneal endotheliitis following penetrating keratoplasty.

Case summary

A 45-year-old male with a history of re-penetrating keratoplasty due to corneal opacity and graft failure after previous penetrating keratoplasty of his right eye in April 2014, visited our clinic for intermittent injection of the right eye for several weeks (7 months postoperative). Corneal edema, diffuse keratic pigmentation and anterior chamber reaction with decreased endothelial cell density were observed in his right eye using the slit lamp examination. Seven months after keratoplasty, corneal graft rejection were determined but clinical findings showed features of CMV-related corneal endotheliitis. Under the impression of CMV corneal endotheliitis, diagnostic paracentesis was performed for CMV real time polymerase chain reaction (RT-PCR). Additionally, the patient was admitted for intravenous ganciclovir and topical ganciclovir therapy. The next day, the RT-PCR results confirmed CMV infection. After 2 weeks of intravenous ganciclovir treatment, the patient was discharged and prescribed oral ganciclovir for 1 month. A month later, the coin-shaped corneal lesion nearly disappeared. There was no evidence of complication or recurrence.


CMV corneal endotheliitis typically presents with coin-shaped keratic pigmentation and can be confirmed with RT-PCR using aqueous humor collected from the anterior chamber. Due to the long period of systemic and topical steroid therapy, the risk of viral endotheliitis is relatively high in patients with a history of penetrating keratoplasty. Corneal graft rejection is similar to corneal endotheliitis in symptoms and clinical features such as ciliary injection, decreased visual acuity, corneal edema or anterior chamber reaction. In patients after penetrating keratoplasty, CMV RT-PCR should be considered if the clinical features suggest viral endotheliitis.


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Figure 1.
Clinical manifestations of cytomegalovirus corneal endotheliitis examined by slit-lamp biomicroscopy. Pre-therapeutic photograph. Diffuse coin-shped keratic precipitates and stromal corneal edema are observed (arrows).
Figure 2.
Clinical finding 7 months after gancyclovir therapy. Coin-shaped keratic pigmentation disappeared and no anterior chamber reaction was remained.
Table 1.
Follow up visual acuity, IOP, specular, CCT
  POD 2 months POD 7 months (at diagnosis) After treatment 1 day After treatment 1 week After treatment 1 month treatment 3 months After treatment 5 months After After treatment 7 months
VA (corrected VA) 20/16 20/16 20/160 20/125 20/100 20/160 20/160 20/125
  (20/80)   (20/125) (20/62.5)        
IOP (mm Hg) 19 23 17 14 17 15 17 24
Endothelial cell density (count/mm2) 2,557 1,231 1,208 1,166 927 931 867 817
CCT (μ m) 612 681 699 706 685 671 634 605

Patient used topical antiglaucoma drug, such as Cosopt®, Alphagan®, Taflotan® before endotheliitis occured and stopped about a week after treatment start. Oral acetazolamide 250 mg twice a day was added after 1 week after treatment.

IOP = intraocular pressure; CCT = central corneal thickness; POD = postoperative day; VA = visual acuity.

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