Development of Cytomegalovirus Corneal Endotheliitis During Long-Term Topical Tacrolimus and Steroid Treatment for Chronic Ocular Surface Inflammatory Diseases

Abstract

Purpose:We report 3 cases of patients with chronic ocular surface inflammatory disease who developed cytomegalovirus (CMV) corneal endotheliitis during immunosuppressant and steroid treatment.Patients and Methods:This is a retrospective observational study analyzing the clinical characteristics and outcomes of 3 patients with ocular surface inflammatory diseases (2 with Mooren ulcer and 1 with idiopathic scleritis) who developed CMV corneal endotheliitis. All patients developed CMV corneal endotheliitis between 8 and 14 months of starting steroid and immunosuppressant treatment, including topical 0.1% tacrolimus. Decimal visual acuity, endothelial counts, and intraocular pressure were analyzed.Results:All patients received topical 0.5% ganciclovir after the diagnosis of CMV corneal endotheliitis, which improved endothelial inflammation. However, all patients developed irreversible mydriasis and required additional surgeries, including endothelial keratoplasty, cataract surgery, and glaucoma surgery. At the final follow-up (14–46 months post-CMV corneal endotheliitis onset), fair outcomes were achieved, as demonstrated by a mean decimal best-corrected visual acuity of 0.3 and a well-controlled intraocular pressure.Conclusions:Topical steroids and immunosuppressants can induce fulminant CMV corneal endotheliitis with cataract progression and irreversible mydriasis. In these cases, early diagnosis and treatment, including topical 0.5% ganciclovir, glaucoma surgery, cataract surgery, and endothelial keratoplasty, are necessary for preserving the patient's vision.

Clinical Features of Glaucoma Associated with Cytomegalovirus Corneal Endotheliitis

“…2,3 Thereafter, CMV corneal endotheliitis has become an established clinical entity through series of reports from worldwide, mainly from Asian countries. [1][2][3][4][5][6][7][8][9] CMV corneal endotheliitis characterized by corneal edema, linear or circular keratic precipitates (KPs), and mild anterior chamber reaction. It sometimes accompanies intraocular pressure (IOP) elevation.…”

“…It sometimes accompanies intraocular pressure (IOP) elevation. [4][5][6][7][8][9] Polymerase chain reaction (PCR) of aqueous humor samples is helpful in confirming the diagnosis. Previous work has demonstrated the efficacy of treatment with topical ganciclovir (GCV) and systemic anti-CMV agent.…”

“…Previous work has demonstrated the efficacy of treatment with topical ganciclovir (GCV) and systemic anti-CMV agent. [4][5][6][7][8][9] In some cases, endothelial decompensation occurs, that may require endothelial keratoplasty. 4,5 Also, persist IOP elevation require glaucoma surgery.…”