Acyclovir treatment in stromal herpetic keratitis

Twenty-five patients with long standing deep stromal herpetic keratitis and iritis were treated with acyclovir (3%) ointment and corticosteroids. All patients healed in about two to four weeks, independent of the duration of the keratitis before acyclovir treatment and independent of the antiviral medication given previously. Recurrences could not be prevented by acyclovir treatment. No serious side effects of acyclovir were noted.     

局部使用作用于肿瘤坏死因子α的反义寡核苷酸对实验性小鼠单疱病毒性脉络膜视网膜炎的影响

目的 观察局部使用作用于肿瘤坏死因子α（TNF-α）的反义寡核苷酸对实验性单疱病毒性脉络膜视网膜炎病理过程的影响。 方法 将50只BALB/c小鼠随机分为实验组和对照组，每组25只。将单纯疱疹病毒-Ⅰ型（HSV-Ⅰ）注入所有小鼠右眼（注射眼）前房内，建立单疱病毒性脉络膜视网膜炎的小鼠模型。实验组中分别于HSV-Ⅰ型感染前1 d，感染后1、4 d，将异硫氰酸荧光素标记的作用于TNF-α的反义寡核苷酸2 μl注射于感染小鼠的左眼（非注射眼）球结膜下;对照组则于相同的时间段内注射等量的磷酸盐缓冲液于感染小鼠的左眼（非注射眼）球结膜下，观察两组小鼠眼部的炎症改变并根据有无前房炎症反应、瞳孔和虹膜血管扩张、白内障形成、玻璃体混浊等行临床评分。于病毒感染后10 d处死所有小鼠，观察其组织学变化并采用酶联免疫吸附试验（ELISA）测定小鼠脉络膜视网膜的TNF α含量。 结果 感染后，两组小鼠右眼均表现为急性炎症改变;实验组小鼠左眼炎症反应临床评分明显小于对照组。组织学观察结果:对照组有12只小鼠左眼表现程度不等的坏死性脉络膜视网膜炎，实验组有2只小鼠左眼表现为轻度的脉络膜视网膜炎，两组间视网膜、脉络膜及睫状体部位炎性细胞计数差异有统计学意义（P＜0.05），而前房、玻璃体腔及虹膜部位无明显差别（P＞0.05）。ELISA测定结果:实验组脉络膜视网膜TNF-α含量为（60±1.25） pg，对照组脉络膜视网膜TNF-α含量为（305±1.03）pg，两者相比差异有统计学意义（P＜0.05）。 结论 采用作用于TNF-α的反义寡核苷酸局部治疗小鼠单疱病毒性脉络膜视网膜炎，能明显降低感染小鼠眼内细胞因子TNF-α的含量，减轻眼内脉络膜视网膜炎症反应。 (中华眼底病杂志, 2006, 22: 245-248)     

Actipol in treating stromal herpetic keratitis

Actipol (0.007% paraaminobenzoic acid--PABA) is a new interferon (IFN) inductor. It was recently introduced into ophthalmological practice. Its efficiency in surface herpetic keratitis is proven. We studied the therapeutic efficiency of actipol in the treatment of stromal herpetic keratitis and compared the results with combined therapy with acyclovir (ACV) and leukocytic IFN. The main group (141 patients) were treated with actipol and the reference group (40 patients) with ACV ointment and leukocytic IFN. Local injections of actipol in combination with its instillations into the conjunctival sac led to cure of 67.3% patients with stromal herpetic keratitis; this treatment was more effective than combined local ACV + leukocytic IFN therapy (clinical cure in 45% cases). Epithelialization in the actipol group was observed 2 days sooner, infiltration resorption and clinical cure 4 days sooner than in the reference group. Relatively high visual acuity in the actipol group was presumably due to the reparogenic effect on the corneal stroma and antithrombotic, fibrinolytic, and antioxidant activity of PABA. Hence, actipol is an effective drug for the treatment of stromal herpetic keratitis, exerting virtually no side effects.     

Topical treatment with nerve growth factor in an animal model of herpetic keratitis

Background In vitro and in vivo studies demonstrated the antiviral efficacy of nerve growth factor (NGF) and its cyto-protective effect in herpes simplex virus (HSV)-infected cells. The aims of this study were to evaluate the role of endogenous NGF in HSV corneal infection, and the effects of topical NGF treatment on herpetic keratitis. Methods Herpetic keratitis was induced in 40 rabbits with the HSV-1 McKrae strain. Animals were divided into four groups, and treated with topical neutralizing anti-NGF antibodies, NGF, acyclovir or balanced salt solution (BSS) respectively. The clinical course of HSV keratitis was evaluated and scored by slit-lamp examination. In addition, biochemical (immunohistochemistry for glycoprotein D) and molecular (nested PCR for glycoprotein D) analyses were carried out to estimate viral replication. Results Treatment with anti-NGF antibodies induced a more severe keratitis associated with increased biochemical and molecular markers of active viral replication. Two animals in this group developed lethal HSV encephalitis. Conversely, topical treatment with NGF induced a significant amelioration of clinical and laboratory parameters when compared to the BSS treated group (control). No significant differences were observed between NGF- and acyclovir-treated groups. Conclusions This study demonstrated the crucial role of endogenous NGF in herpetic keratitis. The comparable effects of NGF and acyclovir confirm the antiviral activity of NGF, and indicate a potential use of topical NGF in herpetic keratitis.     

Topical antisense-oligonucleotides targeting IFN-gamma mRNA improve incidence and severity of herpetic stromal keratitis by cytokine specific and sequence unspecific effects

Background Corneal infection with herpes simplex virus-1 (HSV) can cause an inflammatory eye disease termed herpetic stromal keratitis (HSK). Interferon-gamma (IFN-γ) is known to be involved in the development of this disease. In this study, antisense oligonucleotides targeting IFN-γ mRNA (IFN-γ-ASON) were investigated for their effects in experimental HSK. Methods Splenic cells were used to examine the efficacy of IFN-γ-ASON to decrease IFN-γ- release into the cell culture supernatants as measured by ELISA. Mice were corneally infected with 10⁵ PFU HSV, and IFN-γ-ASON were given subepithelially. Alternatively, mice were infected without any further treatment, received only buffer, or received control oligonucleotides (CON) to observe substance specific effects. The animals were followed up clinically for the signs of herpetic keratitis. On days 14 and 28 post infection (p.i.), animals were sacrificed, and eyes were collected for histological analysis. On day 7 p.i., infectious virus particles in the eyes were determined by a plaque assay. Results While IFN-γ-ASON diminished the content of IFN-γ in a concentration-dependent manner in vitro, CON showed no significant effects. Whereas buffer-treated and only infected mice showed severe necrotizing keratitis on day 14 p.i., this was abolished after treatment with IFN-γ-ASON, even after 28 and 52 days. CON-treated mice also showed an improved HSK on day 14, but not on day 28. The incidence of the disease was also clearly diminished after treatment with IFN-γ-ASON at all time points examined. The number of inflammatory cells in both the central and the peripheral cornea were strongly reduced after the application of IFN-γ-ASON as compared to the controls. In contrast, the infectious viral particles in eyes at day 7 p.i. did not differ between the four groups. Conclusions Topical treatment with IFN-γ-ASON induced a long-term improvement of the course and the incidence of HSK in the murine model. IFN-γ seems to be involved in a proinflammatory manner during the pathogenesis of HSK, while the antiviral defense against HSV was not affected by this topical cytokine inhibition. Unspecific CON induced a transient and cytokine independent improvement of HSK. Some of the data presented in this study were the topic of a short oral presentation held at the 102nd DOG Congress 2004 in Berlin. Financial support: DFG He1877/12-2 and Ernst und Berta Grimmke Stiftung.     

Corneal endothelial changes associated with herpetic stromal keratitis

Wide-field specular microscopy was performed on both eyes of 33 patients with unilateral herpetic stromal keratitis. Endothelial changes were quantitated by computerized morphometric analysis of individual cells. In the 16 patients with disciform keratitis, the corneal endothelium of the affected eyes showed no difference in cell density but demonstrated significant increases of variation in cell size (polymegathism) and shape (pleomorphism) when compared to the cells in the fellow unaffected eyes. The eyes with keratouveitis (17 patients), however, had marked polymegathism and pleomorphism of the endothelium and a distinctly lower endothelial cell density (mean, 19%) than the healthy fellow eyes.     

Immunological aspects of herpetic stromal keratitis

Herpetic stromal keratitis (HSK) is an immune reaction related to herpes simplex virus (HSV) corneal infection, and has many important immunological aspects. CD4(+) T lymphocytes, especially Th1 cells, are the principal mediators for HSK. In addition, neutrophils and antigen-presenting cells play vital roles in HSK. CD8(+) T lymphocytes, B cells, and natural killer cells all participate in the pathogenesis of HSK under certain circumstances. Many molecules are involved in the pathogenesis of HSK. Th1 cytokines such as interleukin 2 (IL-2), IL-12 and interferon gamma, and inflammatory cytokines such as IL-1alpha and IL-6 are especially important ones. Among various chemokines that take part in HSK, MIP-1alpha is one of the most important aggravating factors. Vaccination therapy against HSK has been developed; glycoprotein D is a particularly promising candidate. However, the possibility of HSK exacerbation due to vaccination is the final problem to be solved before vaccination can be clinically applied to HSK. Molecular mimicry theory and bystander activation theory are the two new autoimmune theories that have been advocated. Since genuine autoimmune HSK without HSV growth can hardly be the case in clinical practice, some part of these new theories remains controversial. In the future, better understanding of the pathogenesis of HSK is essential to resolve the paradox between suppressing the immune reaction to avoid corneal scarring and preventing viral proliferation.     

单纯疱疹性角膜基质炎诊疗中的失误和对策

目的 研究单纯疱疹性角膜基质炎(HSK)诊疗中的失误和对策。方法 以含微量地塞米松的复方抗单疱药疱疹灵滴眼剂,≤8.0mm治疗性穿透角膜移植和≥8.5mm深板层角膜移植等三种方法,对87例92眼诊疗失误的HSK作回顾性临床分析。结果 3种治疗方法的治愈率分别为100.0％(39/39),100.0％(3/3)和98.0％(49/50),而复发率(平均随访3年7个月)分别为53.8％(21/39),0.0％(0/3)和2.1％(1/49)。结论 ①HSK临床体征变化的多样性,是导致诊疗失误的主要原因。②单独应用抗单疱药,不符合HSK的发病机理;全身大剂量和/或局部高浓度皮质类固醇,超过了HSK抗炎作用的实际需要,凸显出许多皮质类固醇的不良作用,同样会收到事与愿违的恶果。③含微量地塞米松的复方抗单疱滴眼剂,具有抑毒抗炎双重治疗作用,又避免了大剂量皮质类固醇的不良作用,对HSK疗效卓著,是迄今中外同类药物中的姣姣者。④≥8.5mm的深板层角膜移植术,能够最大限度地清除角膜基质中的病毒抗原,净化潜伏感染基地,是一种对重症HSK安全高效的治疗措施。     

Topical administration of HSV gD-IL-2 DNA is highly protective against murine herpetic stromal keratitis.

PURPOSE: To evaluate the immunopreventive effect of eyedrops that contain gD-IL-2 DNA (a chimeric gene of the glycoprotein D gene of herpes simplex virus type I (HSV-1) and human interleukin-2 (IL-2) on murine herpetic keratitis. METHODS: A plasmid containing gD-IL-2 (pHDLneo1) was constructed. The eyedrops containing 90 microg/10 microL of the DNA was instilled bilaterally into the conjunctival sacs of BALB/c mice on days 0 and 7. Three weeks after the last administration, neutralizing antibody, delayed-type hypersensitivity (DTH), and 51Cr-release from infected targeted cells by lymphocytes from the cervical lymph nodes and spleen were determined. Immunized mice were challenged with HSV-1, after which the clinical signs of the corneal epithelia and stroma were scored. RESULTS: Specific neutralizing antibody was raised and prominent DTH reaction was elicited from immunized mice. Lymphocytes obtained from the local lymph nodes and spleen vigorously potentiated the cytotoxic activity against the virus-infected cells. Clinically, the development of stromal keratitis was completely inhibited, but prevention or reduction of HSV-1 epithelial lesions was not demonstrated statistically. CONCLUSION: Topical immunization with a DNA vaccine encoding gD-IL-2 totally prevented the development of herpetic stromal keratitis. This procedure is a simple and convenient method for possible clinical application in the future.     

羊膜移植治疗难治性单疱病毒性角膜炎合并细菌感染的探讨

目的 探讨羊膜移植对难治性单疱病毒性角膜炎合并细菌感染的治疗效果.方法 难治性单疱病毒性角膜炎合并细菌感染的患者23例23眼.经过角膜刮片及共焦显微镜检查排除真菌及棘阿米巴感染.均在1～3 d的强化抗病毒及抗细菌治疗后接受羊膜移植术,根据患者溃疡深度采用单层或多从羊膜移植.术后仍继续进行抗病毒及抗细菌治疗.结果 术后1～4周,23例角膜溃疡均愈合.结论 羊膜移植能够促进角膜溃疡愈合,是治疗病毒性角膜炎合并细菌感染的一种有效方法.     

Evaluation of topical 0.03% flurbiprofen drops in the treatment of herpetic stromal keratitis

Purpose: The management protocol for herpetic stromal keratitis (HSK) is still controversial. We have attempted to compare the relative efficacy of topical dexamethasone 0.01 % and flurbiprofen 0.03% in combination with topical acyclovir 3% in HSK.
Methods: In this institutional, prospective, randomized, controlled, double-blind study, 45 clinically diagnosed cases of HSK were randomly distributed into three coded treatment groups — topical placebo, dexamethasone 0.01 %, and flurbiprofen 0.03% each in tapering frequency and in combination with acyclovir 3% ointment five times per day for four weeks. Therapeutic response was assessed every third day for four weeks. Decoding of the treatment groups was done at the conclusion of the study and data analysed.
Results: Four-week success rate was 93.3% (14 of 15) in the dexamethasone-acyclovir treatment group, 66.7% (10 of 15) in the flurbiprofen-acyclovir treatment group and 20% (3 of 15) in the placeboacyclovir treatment group.
Conclusion: While dexamethasone in combination with acyclovir gives the best results in HSK with minimal side-effects, the role of topical flurbiprofen seems promising.     

环孢霉素A滴眼液治疗单疱病毒性角膜基质炎疗效观察

目的:观察10g/L环孢霉素A滴眼液治疗单疱病毒性角膜基质炎临床疗效。方法:我院2011-01/2012-01治疗单疱病毒性角膜基质炎患者91例91眼,随机分为两组,A组应用10g/L环孢霉素A滴眼液和更昔洛韦凝胶,B组应用5g/L氯替泼诺滴眼液和更昔洛韦凝胶,其余均为对症治疗,随诊观察6～12(平均10)mo。结果:两组治疗单疱病毒性角膜基质炎疗效无显著性差异,但A组治愈时间平均5.1±2.4d,B组治愈时间平均6.2±2.8d,A组较B组平均治愈时间短。两组治愈率及复发率无统计学差异。结论:对于单疱病毒性角膜基质炎患者应用10g/L环孢霉素A滴眼液能够安全有效治愈,且治愈时间短。     

Cytokine expression in murine corneas during recurrent herpetic stromal keratitis

Purpose: To describe a case of meningococcemia with anterior uveitis. Methods: Observational case report. Results: A 38-year-old woman developed meningococcal septicemia caused by Neisseria meningitidis type B. During her admission, she had pain in her left eye, inflammatory cells, and a fibrinous exudate in the anterior chamber and multiple posterior synechiae, all in the context of an anterior uveitis. She was treated with topical steroids and mydriatics with resolution of ocular inflammation. Conclusions: This case illustrates the possible association between anterior uveitis and a meningococcal septicemia, and the need for careful ophthalmologic examination when a red eye develops in this clinical context.     

Application of FGF-2 to modulate herpetic stromal keratitis

PURPOSE: Herpetic stromal keratitis (SK) is a tissue destructive eye lesion caused by infection of herpes simplex virus-1 (HSV-1). One step by which HSV-1 enters the cell is through binding to surface heparan sulfate proteoglycans (HSPG), a process that can be inhibited by fibroblast growth factor 2 (FGF-2). The current study examined the effect of FGF-2 application on the outcome of ocular HSV infection. METHODS: Vero cells were infected with HSV-1 after preincubation with FGF-2 protein, and viral infectivity was determined by plaque reduction assay. In an in vivo study, mice were ocularly treated with FGF-2 before (plasmid DNA) or after (recombinant protein) HSV-1 infection, and SK lesion severity was observed. Results: Whereas FGF-2 had excellent antiviral effects in vitro, it was without significant inhibitory effects when given as plasmid DNA encoding FGF-2 (100 microg/application) onto the cornea of the susceptible mouse (BALB/c) before virus infection. Only minor antiviral effects of FGF-2 in vivo were initially observed. Interestingly, topical treatment of recombinant FGF-2 protein (50 ng, two times daily until day 10 postinfection) into HSV-1-infected corneas significantly reduced SK lesion severity and incidence, presumably by promoting epithelial ulcer healing. CONCLUSIONS: These results suggest that treatment of FGF-2 has therapeutic effects on herpetic SK progression via its role in wound healing.     

Microdiathermocoagulation in the treatment of herpetic keratitis

The authors analyze the efficacy of microdiathermocoagulation (MDC) in 126 patients with herpetic keratitis. Combined use of MDC and soft contact highly hydrophilic lenses preimpregnated with poludan, an interferon inductor solution, has helped reduce almost twofold the mean period of treatment of 80 patients with dendritic keratitis as compared to idoxuridine monotherapy. The study has shown the advantages of a soft contact lens over ointment dressing prescribed after such microsurgical manipulations to patients with superficial herpetic keratitis. A special microelectrode scarifier is suggested. The efficacy of MDC in the treatment of herpetic stromal keratitis with ulceration has been demonstrated, as well as in the management of superinfection manifestations (purulent ulcer, abscess of the cornea). The technique and the results of MDC are discussed and compared to mechanical abrasion and argon laser coagulation in herpetic keratitis.