Turkiye Klinikleri Journal of Ophthalmology

.: ORIGINAL RESEARCH
Newly Acquired Herpetic Epithelial Keratitis After Penetrating Keratoplasty without Previous History of Herpetic
Keratitis Herpetik Keratit Geçmişi Olmadan Penetran Keratoplasti Sonrası Yeni Edinilmiş Herpetik Epitelyal Keratit
Evin ŞİNGARa, Ayşe BURCUa, Ahmet KADERLİb, Züleyha YALNIZ AKKAYAa, Selma ÖZBEK UZMANa, Firdevs ÖRNEKa
aDepartment of Ophthalmology, University of Health Sciences Ankara Training and Research Hospital, Ankara, TURKEY
bDepartment of Ophthalmology, Muğla Sıtkı Koçman University Faculty of Medicine, Muğla, TURKEY
Turkiye Klinikleri J Ophthalmol. 2020;29(4):316-23
doi: 10.5336/ophthal.2020-75349
Article Language: EN
Full Text
ABSTRACT
 Objective: Herpes simplex virus (HSV) infection may develop either by reactivation of latent HSV in its endogenous foci or exogenous transmission from the transplanted donor cornea after penetrating keratoplasty (PK). In the current study, we aimed to determine the clinic and treatment outcomes of patients without previous history of HSV infection who had newly acquired herpetic epithelial keratitis (HK) after PK. Material and Methods: The medical records of patients who underwent PK for reasons outside of corneal scars due to the HK between January 1995 and February 2016 were retrospectively screened. Results: The incidence of newly developed HK was 1.09% (17/1559). The mean interval between PK and HK was 30.41±39.31 months (range 1-139 months). Dry eye was present in 82.3%, corneal neovascularization in 41.2% and systemic diseases in 23.5% cases with newly acquired HK after PK. At the time of the diagnosis of HK; 82.3% of cases were using topical steroids, 23.5% of cases oral steroids and 11.8% of cases topical cyclosporine-A. In 17.6% cases HK developed after the secondary surgeries following PK. Conclusion: The diagnosis of HK immediately came to mind and treatment was started at once especially in persistent and atypical epithelial defect on corneal grafts. Herpetic epithelial keratitis should be remembered that it can be develop any time after PK.

Keywords: DNA polymerase, simplexvirus; keratitis, herpetic; corneal ulcer; keratoplasty, penetrating
ÖZET
 Amaç: Herpes simpleks virüsü (HSV) enfeksiyonu ya latent HSV'nin endojen odaklarında yeniden aktivasyonu veya penetran keratoplastiden (PK) sonra nakledilen donör korneadan eksojen iletim yoluyla gelişmektedir. Penetran keratoplasti sonrası yeni herpetik epitelyal keratit (HK) tanısı almış olan ve daha önce herpes simpleks virüs enfeksiyonu öyküsü olmayan hastaların klinik ve tedavi sonuçlarını belirlemek amaçlandı. Gereç ve Yöntemler: Herpetik keratit dışı kornea skar nedeniyle Ocak 1995 ile Şubat 2016 arasında PK yapılan hastaların tıbbi kayıtları retrospektif olarak tarandı. Bulgular: Yeni gelişen HK insidansı %1.09 (17/1559) idi. Penetran keratoplasti ile HK gelişim arasındaki süre ortalama 30,41±39,31 ay idi (1-139 ay). Herpetik keratit gelişen olguların %82,3'ünde kuru göz, %41,2'sinde kornea neovaskülarizasyonu ve %23,5'inde sistemik hastalıklar mevcuttu. Herpetik keratit teşhisi sırasında; olguların %82,3'ü topikal steroid, %23,5'i oral steroid ve %11,8'i topikal siklosporin-A kullanıyordu. Olguların %17,6'sında HK, PK'yı takip eden ikincil ameliyatlardan sonra gelişmiştir. Sonuç: Penetran keratoplasti sonrası herpetik epitelyal tanısı, özellikle kornea greftlerinde kalıcı ve atipik epitel defektlerinde hemen akla gelmeli ve tedavi başlanmalıdır. Herpetik epitelyal keratit PK'dan sonra herhangi bir zamanda gelişebileceği unutulmamalıdır.

Anahtar Kelimeler: DNA polimeraz, simpleks virüsleri; keratit, herpetik; korneal ülser; keratoplasti, penetran
REFERENCES:
  1. Al-Dujali LJ, Clerkin PP, Clement C, McFerrin HE, Bhattacharjee PS, Varnell ED, et al. Ocular herpes simplex virus: how are latency, reactivation, recurrent disease and therapy interrelated? Future Microbiol. 2011;6(8):877-907.[Crossref] [PubMed] [PMC] 
  2. Xu F, Sternberg MR, Kottiri BJ, McQuillan GM, Lee FK, Nahmias AJ, et al. Trends in herpes simplex virus type 1 and type 2 seroprevalence in the United States. JAMA. 2006;296(8):964-73.[Crossref] [PubMed] 
  3. Roizman B, Knipe DM, Whitley RJ. Herpes simplex viruses. In: Fields BN, Knipe DM, Howley PM, eds. Fields Virology. 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkin; 2007. p.2503-602.
  4. Nicholls SM, Shimeld C, Easty DL, Hill TJ. Recurrent herpes simplex after corneal transplantation in rats. Invest Ophthalmol Vis Sci. 1996;37(2):425-35.[PubMed] 
  5. Kaye SB, Lynas C, Patterson A, Risk JM, McCarthy K, Hart CA. Evidence for herpes simplex viral latency in the human cornea. Br J Ophthalmol. 1991;75(4):195-200. [Crossref] [PubMed] [PMC] 
  6. Elftman MD, Hunzeker JT, Mellinger JC, Bonneau RH, Norbury CC, Truckenmiller ME. Stress-induced glucocorticoids at the earliest stage of herpes simplex virus-1 infection suppress subsequentantial viral immunity, implicating impaired dendritic cell function. J Immunol. 2010;184(4):1867-75.[Crossref] [PubMed] [PMC] 
  7. El Hayderi L, Raty L, Failla V, Caucanas M, Paurobally D, Nikkels AF. Severe herpes simplex virus type-1 infections after dental procedures. Med Oral Patol Oral Cir Bucal. 2011;16(1):e15-8.[Crossref] [PubMed] 
  8. Tabbara KF, Al Balushi N. Topical ganciclovir in the treatment of acute herpetic keratitis. Clin Ophthalmol. 2010;4:905-12.[Crossref] [PubMed] [PMC] 
  9. Cleator GM, Klapper PE, Dennett C, Sullivan AL, Bonshek RE, Marcyniuk B, et al. Corneal donor infection by herpes simplex virus: herpes simplex virus DNA in donor corneas. Cornea. 1994;13(4):294-304. [Crossref] [PubMed] 
  10. Kaye S, Choudhary A. Herpes simplex keratitis. Prog Retin Eye Res. 2006;25(4):355-80. [Crossref] [PubMed] 
  11. Rezende RA, Bisol T, Hammersmith K, Hofling-Lima AL, Webster GF, Freitas JF, et al. Epithelial herpetic simplex keratitis recurrence and graft survival after corneal transplantation in patients with and without atopy. Am J Ophthalmol. 2007;143(4):623-8. [Crossref] [PubMed] 
  12. Ghosh S, Jhanji V, Lamoureux E, Taylor HR, Vajpayee RB. Acyclovir therapy in prevention of recurrent herpetic keratitis following penetrating keratoplasty. Am J Ophthalmol. 2008;145(2):198-202. [Crossref] [PubMed] 
  13. Kaye SB, Baker K, Bonshek R, Maseruka H, Grinfeld E, Tullo A, et al. Human herpesviruses in the cornea. Br J Ophthalmol. 2000;84(6):563-71. [Crossref] [PubMed] [PMC] 
  14. Biswas S, Suresh P, Bonshek RE, Corbitt G, Tullo AB, Ridgway AE. Graft failure in human donor corneas due to transmission of herpes simplex virus. Br J Ophthalmol. 2000;84(7):701-5.[Crossref] [PubMed] [PMC] 
  15. Rezende RA, Uchoa UBC, Raber IM, Rapuano CJ, Laibson PR, Cohen EJ. New onset of herpes simplex virus epithelial keratitis after penetrating keratoplasty. Am J Ophthalmol. 2004;137(3):415-9. [Crossref] [PubMed] 
  16. Remeijer L, Doornenbal P, Geerards AJ, Rijneveld WA, Beekhuis WH. Newly acquired herpes simplex virus keratitis after penetrating keratoplasty. Ophthalmology. 1997;104(4):648-52.[Crossref] [PubMed] 
  17. Van Rooij J, Rijneveld WJ, Remeijer L, Volker-Dieben HJM, Egginnk CA, Geerards AJM, et al. Effect of oral acyclovir after penetrating keratoplasty for herpetic keratitis: a placebo-controlled multicenter trial. Ophthalmology. 2003;110(10):1916-9.[Crossref] [PubMed] 
  18. Altay Y, Burcu A, Aksoy G, Singar Ozdemir E, Ornek F. Changing indications and techniques for corneal transplantations at a tertiary referral center in Turkey, from 1995 to 2014. Clin Ophthalmol. 2016;10:1007-13.[Crossref] [PubMed] [PMC] 
  19. Beyer CF, Byrd TJ, Hill JM, Kaufman HE. Herpes simplex virus and persistent epithelial defects after penetrating keratoplasty. Am J Ophthalmol. 1990;109(1):95-6.[Crossref] [PubMed] 
  20. Hill JM, Clement C. Herpes simplex virus type 1 DNA in human corneas: what are the virological and clinical implications? J Infect Dis. 2009;200(1):1-4.[Crossref] [PubMed] [PMC] 
  21. Beyer CF, Arens MQ, Hill GA, Rose BT, Beyer LR, Schanzlin DJ. Oral acyclovir reduces the incidence of recurrent herpes simplex keratitis in rabbits after penetrating keratoplasty. Arch Ophthalmol. 1989;107(8):1200-5.[Crossref] [PubMed] 
  22. Haruta Y, Maguire LJ, Rootman DS, Hill JM. Recurrent herpes simplex virus type 1 corneal epithelial lesions after radial keratotomy in the rabbit. Arch Ophthalmol. 1987;105(5):692-4.[Crossref] [PubMed] 
  23. Perry HD, Donnenfeld ED. Topical 0.05% cyclosporin in the treatment of dry eye. Expert Opin Pharmacother. 2004;5(10):2099-107.[Crossref] [PubMed] 
  24. Sack RA, Nunes I, Beaton A, Morris C. Host-defense mechanism of the ocular surfaces. Bioscience Report. 2001;21(4):463-80. [Crossref] [PubMed] 
  25. Rao SN. Treatment of herpes simplex virus stromal keratitis unresponsive to topical prednisolone 1% with topical cyclosporine 0.05%. Am J Ophthalmol. 2006;141(4):771-2. [Crossref] [PubMed] 
  26. Knickelbein JE, Hendricks RL, Charukamnoetkanok P. Management of herpes simplex virus stromal keratitis: an evidence-based review. Surv Ophthalmol. 2009;54(2):226-34.[Crossref] [PubMed] 
  27. Utine CA, Stern M, Akpek EK. Clinical review: topical ophthalmic use of cyclosporin A. Ocul Immunol Inflamm. 2010;18(5):352-61. [Crossref] [PubMed] 
  28. Altenburger AE, Bachmann B, Seitz B, Cursiefen C. Morphometric analysis of postoperative corneal neovascularization after high-risk keratoplasty: herpetic versus non-herpetic disease. Graefes Arch Clin Exp Ophthalmol. 2012;250(11):1663-71. [Crossref] [PubMed] 
  29. Garcia DD, Shtein RM, Musch DC, Elner VM. Herpes simplex virus keratitis: histopathologic neovascularization and corneal allograft failure. Cornea. 2009;28(9):963-5. [Crossref] [PubMed] [PMC] 
  30. Goodfellow JF, Nabili S, Jones MNA, Nguyen DQ, Armitage WJ, Cook SD, et al. Antiviral treatment following penetrating keratoplasty for herpetic keratitis. Eye (Lond). 2011;25(4):470-4. [Crossref] [PubMed] [PMC] 
  31. Garcia DD, Farjo Q, Musch DC, Sugar A. Effect of prophylactic oral acyclovir after penetrating keratoplasty for herpes simplex keratitis. Cornea. 2007;26(8):930-4.[Crossref] [PubMed] 
  32. Bachmann B, Taylor RS, Cursiefen C. Corneal neovascularisation as a risk factor for graft failure and rejection after keratoplasty: an evidence-based metaanalysis. Ophthalmology. 2010;117(7):1300-5. e7. [Crossref] [PubMed] 

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