Recurrent herpetic keratitis in penetrating keratoplasty

In a retrospective study we evaluated 49 consecutive penetrating keratoplasties for herpes simplex keratitis. Mean follow-up was 44.2 months. Survival analysis with Kaplan—Meier curve showed an overall survival rate (clear graft) of 88% at one year, 76% at two years and 72% at four years postoperatively. Survival analysis showed a recurrence-free survival rate of 72% at one year, 59% at two years and 51% at four years postoperatively. Of the 13 non-primary graft failures, 9 happened in eyes with an HSV recurrence. Recurrence of HSV infection occurred in 18 (39%) eyes at an average of 12.6 months after surgery (range 0.3–46). Five (28%) of the recurrences occurred within two months after the start of steroid treatment for rejection. Nine (50%) of the recurrence cases resulted in a clouded graft at the end of follow-up. 73% of the eyes with a clear graft had a VA of 0.25 or better. We conclude from these data that a recurrence of a herpetic infection following corneal transplantation is the main reason for graft failure in this group.     

口服阿昔洛韦在单疱病毒性角膜炎行角膜移植术后的应用

目的　评价单纯疱疹病毒性角膜炎患者行穿透性角膜移植术后,口服阿昔洛韦预防单纯疱疹病毒性角膜炎复发的疗效。方法　1999年1月至2 0 0 3年12月单纯疱疹病毒性角膜炎5 2例5 2眼行穿透性角膜移植术,术后给予口服阿昔洛韦2 0 0mg 5次/d ,服用2m～3m后减为4 0 0mg 2次/d ,继续服用3m后停止,分析单纯疱疹病毒性角膜炎复发的情况。结果　在口服阿昔洛韦期间,无一例出现单纯疱疹病毒性角膜炎的复发。术后经12m～38m (2 2 .8±9. 6 )的随访,4 9眼植片透明,3眼因排斥反应植片混浊。32眼(6 1 .5 % )最佳矫正视力好于0 . 5 ,4 9眼(94 . 2 % )最佳矫正视力好于0 . 1,3眼(5 . 8% )低于0 . 1。结论　口服阿昔洛韦能有效预防单纯疱疹病毒性角膜炎行穿透性角膜移植术后的复发     

Antiviral treatment following penetrating keratoplasty for herpetic keratitis

Purpose

To assess the effect of antiviral treatment on corneal graft survival following penetrating keratoplasty for herpetic keratitis.

Methods

Retrospective cohort study of 454 patients receiving primary penetrating keratoplasties (PKs) for viral infection reported to NHS Blood and Transplant (NHSBT) between April 1999 and June 2005. Follow-up data were available on 403 PKs. Kaplan–Meier survival estimates were used to determine graft survival for the three treatment groups: no medication, topical antiviral, and oral antiviral medication. A Cox regression model was used to investigate the combined effects of all additional factors on graft failure. The model was fitted using all pre-operative factors first and then post-operative factors including type of antiviral medication were included.

Results

Patients who received oral antiviral medication post-operatively had consistently better graft survival than those receiving no medication or only topical medication. Patients receiving oral antivirals were less than a third as likely to have a failed graft at 5 years compared with those on no antiviral medication (relative risk (RR) 0.3, CI: 0.2–0.7, P=0.002). Other factors that were found to influence the risk of graft failure were the presence of deep corneal vascularisation (P=0.009), PK performed for therapeutic reasons (P=0.03), large diameter grafts (P=0.04), and experiencing a rejection episode (P=0.003).

Conclusion

Oral antiviral treatment reduces the risk of graft failure in patients undergoing primary PK for herpetic keratitis and should be routinely used in this group of patients post-operatively unless contra-indicated.     

穿透性角膜移植术治疗单纯疱疹病毒性角膜炎后复发的危险因素

目的研究单纯疱疹病毒性角膜炎在行穿透性角膜移植术（PKP）治疗后复发的危险因素,临床特征和治疗方式的选择。方法回顾性病例研究。回顾性分析2000年1月至2012年7月在青岛眼科医院因药物治疗无效行穿透性角膜移植术的单纯疱疹病毒性角膜炎患者329例（329眼）。观察分析其术后首次复发的情况,包括复发时间、复发类型、复发的危险因素以及复发后的治疗转归。PKP术后复发的相关危险因素的比较应用卡方检验。在一个回归模型中应用初始单变量分层分析以鉴定和选择复发的重要的相关因素。结果穿透性角膜移植术后有33眼（10％）复发,复发类型主要为上皮型,18例（54％）,复发病灶主要集中于植片与植床交界处（63％）,复发时间从2周到13年不等。复发的相关危险因素包括：免疫排斥（X2=47．09,P〈0．01）、继发性青光眼（X2=26．38,P〈0．05）、并发性白内障行白内障手术（x2=7．31,P〈0．05）、上呼吸道感染（X2=5．60,P〈0．05）、病灶累及角膜缘（x2=8．30,P〈0．05）。复发病例中上皮型有10例经单纯药物治疗有效,其余基质型和内皮型（包括由上皮型转化而来）有5例行结膜瓣覆盖术治疗,12例行单层或双层羊膜覆盖术,6例行二次PKP术。所有复发病例经药物或手术治疗后平均随访（24．6±5．4）个月,植片透明率达46％。结论免疫排斥、继发性青光眼（未行手术）、白内障手术、上呼吸道感染、病灶累及角膜缘,是穿透性角膜移植术后复发的危险因素,基于复发的临床特征和危险因素,选择合适的预防方式和治疗方式可有效控制复发。     

Bacterial keratitis after penetrating keratoplasty

Bacterial keratitis continues to be a serious problem in developing countries. The authors studied 881 patients who had undergone penetrating keratoplasty (total of 947 procedures) from January 1983 to March 1986 at the King Khaled Eye Specialist Hospital, Riyadh, Saudia Arabia. All patients were followed for at least 6 months. Clinical evidence of bacterial keratitis developed in 113 (11.9%) eyes with penetrating keratoplasties in 108 patients. The causative organisms among those patients included: Streptococcus pneumoniae, 29 (26%); Staphylococcus epidermidis, 24 (21%); Pseudomonas aeruginosa, 13 (12%); Staphylococcus aureus, 5 (4%); Hemophilus influenzae, 5 (4%); Moraxella spp, 5 (4%); alpha-hemolytic streptococcus, 5 (4%); and other bacteria, 27 (25%). In addition, postoperative epithelial defects that required hospital admission for treatment developed in 21 (2.2%) patients. Herpetic keratitis developed in three (0.3%) patients and fungal keratitis developed in 1 (0.1%). Statistically significant predisposing risk factors included: trichiasis (P less than 0.0001), epithelial defects (P less than 0.0001), soft contact lens wear (P less than 0.0001), and eroding sutures (P less than 0.0001). The authors believe that the incidence of postoperative bacterial keratitis can be minimized or avoided by appropriate selection of patients for penetrating keratoplasties as well as good preoperative and postoperative management of associated ocular conditions.     

New onset of herpes simplex virus epithelial keratitis after penetrating keratoplasty

PURPOSE: To report a series of patients with no previous history of herpes simplex virus (HSV) infection who had new onset of herpetic keratitis after penetrating keratoplasty (PK). DESIGN: Noncontrolled, retrospective case series. METHODS: We included in the study the patients who had new onset of herpetic keratitis after penetrating keratoplasty for corneal diseases unrelated to HSV infection who were seen at the Cornea Service at Wills Eye Hospital (Philadelphia, Pennsylvania) from January 1996 to December 2002. The diagnosis of HSV epithelial keratitis was based on clinical characteristics of either a classic herpetic dendrite, a geographic ulcer, or a nonhealing epithelial defect that responded only to antiviral therapy. RESULTS: Fourteen patients were included in the study. Eight of these (57%) had presented with a geographic ulcer whereas six patients (43%) had a classic dendrite. The most common primary corneal disease that led to PK was pseudophakic bullous keratopathy (36%), followed by keratoconus (29%), Fuchs dystrophy (21%), and corneal scar unrelated to HSV (14%). CONCLUSIONS: The ophthalmologist should be aware of the possibility of herpetic keratitis in eyes after PK, even in patients with no previous history of HSV infection.     

Acyclovir therapy in prevention of recurrent herpetic keratitis following penetrating keratoplasty

PURPOSE: To compare systemic vs topical acyclovir therapy for the prevention of recurrence of herpetic keratitis following penetrating keratoplasty (PK). DESIGN: A retrospective observational study. METHODS: Patients who underwent PK for herpetic eye disease (HED) and prophylactically received acyclovir therapy postoperatively, either systemically (26 eyes) or topically (29 eyes), were analyzed. The main parameters evaluated were recurrence of herpetic keratitis, graft rejection, visual acuity, and graft survival rate. RESULTS: Mean average follow-up period was 24.7 +/- 3.6 months and 23.5 +/- 2.3 months in the systemic and topical group, respectively (P = 0.73). The average duration of prophylactic antiviral therapy in systemic group was 16.1 +/- 4.8 months and in topical group was 15.1 +/- 3.5 months (P = .59). Recurrence of herpetic keratitis was seen in 12% in the systemic group compared to 55% in the topical group (P < .001). More eyes in topical group 15 (52%) had rejection episodes than in the systemic group 5 (19%) (P < .001). A best-corrected visual acuity of > or = 20/40 was achieved in 31% and 7% eyes in the systemic and topical group, respectively, at the end of two years (P = .002). The clear graft survival rate in the systemic and topical acyclovir receiving group was 96.2% vs 86.2% at 12 months, and 88.5% vs 65.5% at 24 months, respectively. CONCLUSION: Systemic acyclovir is more effective than topical acyclovir in achieving better graft outcomes after PK for HED.     

Effect of prophylactic oral acyclovir after penetrating keratoplasty for herpes simplex keratitis

PURPOSE: To determine the effect of routine use of prophylactic oral acyclovir after penetrating keratoplasty (PK) for herpes simplex virus (HSV) keratitis on recurrence, rejection, and graft failure rates. METHODS: Records from 70 consecutive patients who underwent PK for HSV keratitis at the W.K. Kellogg Eye Center between August 1, 1990, and December 31, 2000, were reviewed. Data collected included preoperative disease activity, duration, host vascularity, pre- and postoperative vision, and antiviral use. Particular attention was given to all episodes of HSV recurrence, graft rejection, and failure. RESULTS: Fifty-six patients (80%) were treated with prophylactic oral acyclovir after surgery. This cohort experienced fewer episodes of rejection (P = 0.006) and better overall graft survival (P = 0.04) than those who were not treated with prophylactic oral antivirals. There was no statistically significant difference in recurrence-free survival between the 2 groups (P = 0.22). Cox regression analysis failed to identify any single variable as a statistically significant predictor of recurrence, rejection, or graft failure. CONCLUSIONS: Prophylactic oral acyclovir use after PK for HSV keratitis is associated with decreased episodes of rejection and improved graft survival.     

Infectious keratitis after penetrating keratoplasty]

PURPOSE: To investigate the prevalence of microbial keratitis, predisposing risk factors, the spectrum of pathogens and the prognosis for graft survival and visual outcome in patients who developed microbial keratitis following penetrating keratoplasty (PK). MATERIAL: and methods: We reviewed 16 cases (15 patients) of microbial keratitis after PK. In all cases, corneal scrapings were obtained and microbiologically analyzed. Efficacy of treatment was evaluated by anatomical (clarity of graft) and visual recovery. RESULTS: Principal indications for PK were pseudophakic bullous keratopathy (50%) and microbial keratitis in the previous graft (25%). Sixty-three per cent of infections occurred within 1 year of PK. Principal predisposing risk factors were suture-related problems (44%) and microbial keratitis in the previous graft (25%). All of the scrapings were positive according to the microbiological evaluation with gram-positive cocci (64%), gram-positive rods (12%), fungi (18%), and Acanthamoeba (6%). We found 1 case of polymicrobial infection. Best visual and anatomical results were observed in nonadvanced cases and/or these treated early. After medical and surgical treatments, 8 patients (50%) had a clear graft and 10 patients (63%) had visual acuity less than 20/200. CONCLUSION: Postoperative control of risk factors and early recognition of infectious complications may decrease the incidence of severe microbial keratitis after PK.     

穿透性角膜移植术治疗单纯疱疹病毒性角膜炎的疗效分析

目的观察并评价单纯疱疹病毒性角膜炎(herpes simplex keratitis,HSK)行穿透性角膜移植术(penetrating keratoplas-ty,PKP)的治疗效果。方法对74例(74眼)HSK患者行PKP后进行回顾性研究,观察术后视力、角膜内皮情况、免疫排斥及HSK复发的情况。结果患者术后视力恢复良好,术后18个月全部脱盲(最佳矫正视力>0.05),且术后24个月最佳矫正视力>0.5者占60.8%。角膜内皮细胞密度在术后6个月、12个月及24个月分别为(2325.7±516.6)mm-2、(2070.5±647.8)mm-2及(1825.9±630.3)mm-2;术后6个月、12个月、24个月角膜内皮细胞丢失率在有无出现免疫排斥患者间比较,差异均无统计学意义(P1=0.961,P2=0.305,P3=0.151),但出现免疫排斥患者的个体差异较大。术后24个月复发率及免疫排斥率分别为9.46%和28.38%。结论为避免PKP术后HSK复发及免疫排斥反应的发生,强调术后合理性、规范性及针对性的用药,特别是术后抗病毒药物的应用;重视术后随访,做到早发现、早诊断并及时干预治疗。此外,长时间户外日光照射也可能是诱发患者HSK复发的因素。