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S. Winterhalter, A. K. Maier, S. Özlügedik, J. Rottler, M. Klamann, K. Huber, A. M. Joussen; Efficacy of Postoperative Immunosuppression After Keratoplasty in Herpetic Keratitis. Invest. Ophthalmol. Vis. Sci. 2010;51(13):1132.
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Recurrence of herpes keratitis and immune reactions are the major cause for graft failures after penetrating keratoplasty as a consequence of herpes infection. No treatment regime is yet considered standard of care. This retrospective study analyzes the long-term effectiveness of combined systemic acyclovir and immunosuppressive therapy with cyclosporine A or mycophenolate mofetil after high risk keratoplasty in herpetic keratitis.
A total of 87 high risk keratoplasties treated with postoperative combined systemic acyclovir and immunosuppressive therapy with cyclosporine A or mycophenolate mofetil were analyzed retrospectively according to the therapeutic regimen, the degree of preoperative corneal vascularization, and tissue matching of the graft. Endpoints included immunological graft rejection, recurrence of the herpes keratitis, graft failure, and visual acuity.
There was an overall trend towards an improvement of visual acuity. Graft failure occurred in 13.1%, in all cases after termination of immunosuppression with MMF or CSA. In 4 of 11 cases immune rejections caused graft failure. In 5 cases immune rejection was noticed during and in 18 cases after immunosuppression. Patients with 3-4 quadrants of corneal vascularization showed significantly higher rates of graft rejection than patients with 1-2 quadrants vascularized or avascular corneas. Herpes recurrence occurred in 31.8%, in 5 cases during and in 18 cases after immunosuppression, and caused 18.2% of graft failure. In 7 of 23 cases graft rejection was induced by herpes recurrence. Tissue matching decreased neither the risk for immune rejections and herpes recurrences nor the risk for graft failure significantly. Between CSA and MMF no significant differences according to the efficacy could demonstrated.
Graft survival rate and functional outcome after postoperative antiviral and immunosuppressive treatment in cases of penetrating keratoplasties after herpes infection are comparable to results of normal-risk keratoplasties despite existing high risks for immune rejections or herpes recurrences.
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