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Sadeer B. Hannush, William B. Neusidl, Ralph C. Eagle, Lorena Riveroll-Hannush, Brian J. Sperling; Cytomegalovirus (CMV) Corneal Endotheliitis Masquerading as Allograft Rejection. Invest. Ophthalmol. Vis. Sci. 2012;53(14):2382.
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To report two cases of cytomegalovirus (CMV) corneal endotheliitis masquerading as allograft rejection.
Two male patients, 70 and 72 years of age, underwent endothelial keratoplasty for Fuchs' corneal endothelial dystrophy. During the first postoperative year, both presented with decreased visual acuity paralleled by the appearance of keratic precipitates on the endothelial graft, graft and host stromal edema, and mild anterior chamber reaction. Corneal allograft rejection was suspected. Both patients were treated with topical and periocular steroids, with no improvement in symptoms or clinical findings. The grafts went on to decompensation. On repeat grafting, the original endothelial grafts were submitted for pathologic examination.
Microscopic examination of the failed endothelial grafts revealed an atrophic endothelium with large cells having prominent eosinophilic intracytoplasmic inclusions. Large intranuclear inclusions were also identified. These large cells showed intensely positive immunoreactivity for cytomegalovirus. Anterior chamber aqueous taps on both patients revealed CMV by polymerase chain reaction (PCR) (52,800 and 42,100 copies/ml respectively). Treatment consisted of oral valganciclovir and topical ganciclovir. Both repeat grafts remain clear.
Cytomegalovirus (CMV) corneal endotheliitis is a recently recognized condition in immunocompetent patients receiving corneal allografts that may mimic allograft rejection. Traditional treatment with increased local immunosuppression may lead to worsening of the symptoms and clinical findings. Instead, consideration should be given to initiating CMV-specific local and systemic antiviral therapy.
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