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A Woman With Intraocular Inflammation After Descemet Membrane Endothelial Keratoplasty

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

An 81-year-old woman with systemic hypertension and atrial fibrillation underwent Descemet membrane endothelial keratoplasty (DMEK) for visual acuity of counting fingers because of postphacoemulsification bullous keratopathy with no prior episodes of inflammatory eye disease (Figure 1A). Her best-corrected visual acuity (BCVA) improved to 20/40 two weeks later, limited because of a preexisting corneal scar.

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Cytomegalovirus (CMV) endotheliitis

B. Obtain polymerase chain reaction of aqueous humor for cytomegalovirus (CMV) DNA

The presence of KPs unresponsive to increased topical steroids should raise suspicion of an etiology other than immunologic rejection (choice A), a distinction that may be challenging.1 This patient had coin-shaped aggregates of KP and an elevated IOP in the setting of relative immunosuppression because of topical steroid use. This should raise concern for viral infection, particularly as the incidence of graft rejection after DMEK is low compared with other forms of keratoplasty.2 Although IOP elevation is characteristic of viral endotheliitis,1 the contribution of steroid response cannot be excluded in this patient. Aqueous polymerase chain reaction (PCR) was performed (choice B) and CMV DNA was detected. The lack of vitritis, capsular opacities, corneal stromal infiltrate, and negative donor rim culture results decreased the likelihood of chronic fungal or bacterial graft infection and/or endophthalmitis, making choice C an unnecessarily aggressive option. Empirical treatment with acyclovir would have failed in this case, as it is ineffective against CMV because this virus does not use a viral thymidine kinase3 (choice D).

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Article Information

Corresponding Author: Nathaniel Nataneli, MD, BronxCare Health System, Selwyn Avenue, Ste 1C Bronx, NY 10457 (natan7@gmail.com).

Published Online: July 30, 2020. doi:10.1001/jamaophthalmol.2020.1337

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Tan  TE , Tan  DTH .  Cytomegalovirus corneal endotheliitis after Descemet membrane endothelial keratoplasty.   Cornea. 2019;38(4):413-418. doi:10.1097/ICO.0000000000001847PubMedGoogle ScholarCrossref
2.
Deng  SX , Lee  WB , Hammersmith  KM ,  et al.  Descemet membrane endothelial keratoplasty: safety and outcomes: a report by the American Academy of Ophthalmology.   Ophthalmology. 2018;125(2):295-310. doi:10.1016/j.ophtha.2017.08.015PubMedGoogle ScholarCrossref
3.
Joye  A , Gonzales  JA .  Ocular manifestations of cytomegalovirus in immunocompetent hosts.   Curr Opin Ophthalmol. 2018;29(6):535-542. doi. doi:10.1097/ICU.0000000000000521PubMedGoogle ScholarCrossref
4.
Koizumi  N , Inatomi  T , Suzuki  T ,  et al; Japan Corneal Endotheliitis Study Group.  Clinical features and management of cytomegalovirus corneal endotheliitis: analysis of 106 cases from the Japan corneal endotheliitis study.   Br J Ophthalmol. 2015;99(1):54-58. doi:10.1136/bjophthalmol-2013-304625PubMedGoogle ScholarCrossref
5.
Basilious  A , Chew  HF .  Topical ganciclovir for prophylaxis of cytomegalovirus endotheliitis in endothelial keratoplasty.   Cornea. 2019;38(1):120-122. doi:10.1097/ICO.0000000000001797PubMedGoogle ScholarCrossref
6.
Koizumi  N , Miyazaki  D , Inoue  T ,  et al.  The effect of topical application of 0.15% ganciclovir gel on cytomegalovirus corneal endotheliitis.   Br J Ophthalmol. 2017;101(2):114-119. doi:10.1136/bjophthalmol-2015-308238PubMedGoogle ScholarCrossref
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