Prevalence of herpes simplex virus type 1 glycoprotein G (gG) and gI genotypes in patients with herpetic keratitis.

AIM: Recent phylogenetic analyses on the herpes simplex virus type 1 (HSV-1) genes US4, encoding glycoprotein G (gG) and US7, encoding gI, of clinical HSV-1 isolates have led to the classification of HSV-1 into three genotypes, arbitrarily designated as A, B and C. The prevalence of the HSV-1 gG and gI genotypes and their potential disease association was determined in a large cohort of patients with herpetic keratitis (HK). METHODS: Primary corneal HSV-1 isolates of 178 HK patients were genotyped by a PCR-based restriction fragment length polymorphism method targeting the viral genes US4 and US7. RESULTS: Genotype B was more frequently expressed by the corneal HSV-1 isolates compared with genotypes A and C. Fifty-five of 178 corneal isolates (31%) had different genotypes in both loci. No clinically relevant associations were observed between the HSV-1 genotypes and disease outcome in the HK patients studied. CONCLUSIONS: The data presented demonstrate a high frequency of recombinant corneal HSV-1 isolates and suggest that clinical outcome of HSV-1-induced keratitis is independent of a gG or gI genotype.

Suture-related complications following keratoplasty: a 5-year retrospective study.

PURPOSE: To study the incidence of suture-related complications following penetrating keratoplasty (PK) and their effect on the success of corneal grafting. METHODS: The records of 332 patients receiving 361 grafts in 1993 and 1994 were reviewed, and suture-related complications were recorded. These complications were divided into five groups: suture erosions, infiltrates at the suture sites, infectious keratitis, loose sutures with imminent wound dehiscence, and wound dehiscence after suture removal. RESULTS: Occurrence rates were suture erosions, 10.8%; infiltrates, 9.4%; infectious keratitis related to sutures, 3.3%; loose sutures with imminent wound separation in need of surgical repair, 8.3%; and wound dehiscence following suture removal, 2.4%. CONCLUSIONS: Suture-related complications frequently occur after PK. Infectious keratitis and wound separations needing surgical repair may lead to loss of best-corrected visual acuity due to scarring, induced allograft reactions, and/or increased astigmatism. Recommendations for post-PK suture management are proposed.

Herpes simplex virus 1 transmission through corneal transplantation.

Genetic characterisation of herpes simplex virus type 1 (HSV-1) DNA isolated from a donor cornea before and after corneal transplantation demonstrated the transmission of HSV-1 through transplantation. This study is the first to provide conclusive evidence for the transmission of HSV-1 by penetrating keratoplasty with subsequent reactivation of donor-derived HSV-1 in the transplanted cornea.

A quick surgical technique for deep, anterior lamellar keratoplasty using visco-dissection.

PURPOSE: To describe a new surgical technique for deep, anterior lamellar keratoplasty using a viscoelastic for dissection of Descemet's membrane (DM) from the posterior stroma. METHODS: Through a paracentesis, aqueous was exchanged by air to visualize the posterior corneal surface-i.e., the air-to-endothelium interface. Using the interface as a reference plane, a 30 gauge needle was inserted into the cornea to just anterior to DM. Viscoelastic was injected to separate DM from the posterior stroma, and a recipient, anterior lamella was excised. A full-thickness donor button was sutured into the recipient bed, after stripping its DM. RESULTS: In 25 eye bank eyes, the procedure could be completed in 20 eyes; in 5 eyes, DM ruptured during visco-dissection. With light microscopy, dissection depth was located at the level of DM. In two patient eyes the procedure could be completed. In a third patient eye DM ruptured during visco-dissection, and the procedure was converted into a penetrating keratoplasty. CONCLUSION: Using visco-dissection, a lamellar keratoplasty can be performed quickly, with the donor-to-recipient interface just above the recipient DM, i.e., with a nearly perfect anatomical replacement of all corneal stroma. There is substantial risk of rupture or microperforation of DM during surgery.

Herpes simplex virus-specific T cells infiltrate the cornea of patients with herpetic stromal keratitis: no evidence for autoreactive T cells.

PURPOSE: Herpetic stromal keratitis (HSK) is a T-cell-mediated inflammatory disease initiated by a herpes simplex virus (HSV) infection of the cornea. Recently, studies in the HSK mouse model have shown that the immunopathogenic T cells are directed against the HSV protein UL6 cross-reacting with an unknown corneal autoantigen. Whether this type of autoimmunity plays a role in human HSK was analyzed. METHODS: T-cell lines (TCLs) were generated from corneal buttons of 12 patients with different clinical stages of HSV-induced necrotizing stromal keratitis (n = 9) or immune stromal keratitis (n = 3). The initiating virus was identified by polymerase chain reaction and immunohistology performed on the corneal buttons. Peripheral blood mononuclear cells (PBMCs) were isolated, and B cell lines (BLCLs) were generated by transformation with Epstein-Barr virus. Proliferative responses of these intracorneal TCLs were determined by culturing T cells with autologous BLCLs infected with HSV-1, HSV-2, wild-type vaccinia virus (VV-WT), or VV expressing HSV-1 UL6 (rVV-UL6). Alternatively, T cells were incubated with PBMCs pulsed with human cornea protein extract. RESULTS: Irrespective of clinical diagnosis or treatment, T cells were recovered from the corneal buttons of all the 12 HSK patients. The intracorneal TCLs of 9 of the 12 HSK patients showed HSV-specific T-cell reactivity. In none of the TCLs, T-cell reactivity against HSV-1 UL6 or human corneal antigens was detected. CONCLUSIONS: These data suggest that the potentially immunopathogenic intracorneal T-cell response in HSK patients is directed to the initiating virus and not to a human corneal autoantigen or HSV-1 UL6.

Amplification of reiterated sequences of herpes simplex virus type 1 (HSV-1) genome to discriminate between clinical HSV-1 isolates.

Herpes simplex virus type 1 (HSV-1)-related disease ranges from a localized, self-limiting illness to fatal disease in immunocompromised individuals. The corneal disease herpetic keratitis may develop after reactivation of a latent virus or reinfection with an exogenous herpesvirus. Molecular analysis of the virus involved may allow distinction between these two options. The HSV-1 genome contains several hypervariable regions that vary in numbers of reiterating regions (reiterations I to VIII [ReI to ReVIII]) between individual strains. Twenty-four HSV-1 clones, derived by subcloning of HSV-1 (strain F) twice in limiting dilutions, were tested in a PCR-based assay to analyze the stabilities of ReI, ReIII, ReIV, and ReVII. ReI and ReIII proved to vary in size upon subcloning, whereas ReIV and ReVII were stable. Subsequently, 37 unrelated isolates and 10 sequential isolates from five patients, all with HSV-1-induced keratitis, were genotyped for ReIV and ReVII. Of the 37 unrelated samples, 34 (92%) could be discriminated, while the genotypes of the viruses in sequential samples were identical for each individual. Conclusively, the data show that the approach presented allows the rapid and accurate discrimination of HSV-1 strains in studies that address the transmission and pathogenesis of HSV-1 infections.

A new surgical technique for deep stromal, anterior lamellar keratoplasty.

AIMS: To describe a new surgical technique for deep stromal anterior lamellar keratoplasty. METHODS: In eye bank eyes and sighted human eyes, aqueous was exchanged by air, to visualise the posterior corneal surface--that is, the "air to endothelium" interface. Through a 5.0 mm scleral incision, a deep stromal pocket was created across the cornea, using the air to endothelium interface as a reference plane for dissection depth. The pocket was filled with viscoelastic, and an anterior corneal lamella was excised. A full thickness donor button was sutured into the recipient bed after stripping its Descemet's membrane. RESULTS: In 25 consecutive human eye bank eyes, a 12% microperforation rate was found. Corneal dissection depth averaged 95.4% (SD 2.7%). Six patient eyes had uneventful surgeries; in a seventh eye, perforation of the lamellar bed occurred. All transplants cleared. Central pachymetry ranged from 0.62 to 0.73 mm. CONCLUSION: With this technique a deep stromal anterior lamellar keratoplasty can be performed with the donor to recipient interface just anterior to the posterior corneal surface. The technique has the advantage that the dissection can be completed in the event of inadvertent microperforation, or that the procedure can be aborted to perform a planned penetrating keratoplasty.

Posterior lamellar keratoplasty for a case of pseudophakic bullous keratopathy.

PURPOSE: To describe a new surgical technique for posterior corneal transplantation. METHODS: An elderly patient had painful, pseudophakic bullous keratopathy with low visual potential. Through a 9.0-mm scleral tunnel incision, a midstromal pocket was dissected across the cornea, and a posterior lamellar disk 7.0-mm in diameter, which consisted of posterior stroma, Descemet membrane, and endothelium, was excised. A similarly shaped donor posterior disk was implanted in the recipient opening without suture fixation, and the scleral incision was sutured. RESULTS: Throughout the postoperative period, the posterior corneal transplant remained clear and in position. Three months after surgery, the "suture-in" astigmatic error was 3.5 diopters. Pachymetry measured 0.44 mm. CONCLUSION: Posterior lamellar keratoplasty may be a new surgical approach with which to manage corneal endothelial disorders.

The future of lamellar keratoplasty.

New surgical techniques in lamellar keratoplasty, including phototherapeutic keratectomy, automated lamellar keratectomy, plano-epikeratoplasty, deep anterior lamellar keratoplasty, combined amniotic membrane and limbal transplantation, large-diameter corneoscleral lamellar keratoplasty, and posterior lamellar keratoplasty, have recently become available. These procedures broaden the array of treatments for corneal disorders and may be used as alternatives to penetrating keratoplasty.

Identification and characterization of herpes simplex virus-specific CD4+ T cells in corneas of herpetic stromal keratitis patients.

Herpetic stromal keratitis (HSK) is a corneal disease initiated by a herpes simplex virus (HSV) infection with a postulated T cell-mediated immunopathology. To study the antigen specificity of cornea-infiltrating T cells in HSK patients, T cells were isolated and expanded by mitogenic stimulation from corneas of 2 patients with HSV-1-mediated HSK. A substantial number of the T cell clones (TCCs) obtained from these T cell lines were HSV-specific. All HSV-specific TCCs were of the CD3+CD4+CD8- phenotype. These TCCs responded to autologous HSV-infected corneal keratocytes, which expressed HLA class II molecules following incubation with interferon-gamma. Upon HSV-specific stimulation, all TCCs secreted interleukin-4, interleukin-5, and interferon-gamma. The data presented suggest that HSV-specific CD4+ T cells play a role in the immunopathogenesis of HSK in humans and that corneal keratocytes may act as antigen-presenting cells in this local T cell response.

Influence of topical human epidermal growth factor on postkeratoplasty re-epithelialisation.

AIM: To test the efficacy and safety of recombinant human epidermal growth factor (hEGF) on corneal re-epithelialisation following penetrating keratoplasty. METHODS: A prospective, randomised, placebo controlled study was carried out in which patients were matched for diagnosis and received either hEGF ophthalmic solution (30 micrograms/ml or 100 micrograms/ml) or placebo in a double masked fashion. Matched pairs of patients received donor corneas from the same donor and were operated by the same surgeon on the same day. At the end of surgery all donor epithelium was removed mechanically. Patients were examined twice daily and fluorescein stained photographs were taken until the epithelium had closed. The area of the defect was measured by planimetry of the fluorescein stained defect on the photographs. RESULTS: There were no significant differences in re-epithelialisation of the donor cornea between the placebo group and the group treated with 30 micrograms/ml hEGF. Time until complete closure was slightly longer with 100 micrograms/ml hEGF compared with 30 micrograms/ml hEGF and with placebo. Mean healing rate of the epithelial defect with 100 micrograms/ml hEGF was significantly slower than in the other groups. CONCLUSION: No significant acceleration of corneal re-epithelialisation was demonstrated with the use of recombinant hEGF after penetrating keratoplasty in humans.

Newly acquired herpes simplex virus keratitis after penetrating keratoplasty.

BACKGROUND: After penetrating keratoplasty for reasons unrelated to herpes simplex virus (HSV) keratitis, any nonspecific epithelial defect may still be caused by HSV. The purpose of this study is to determine the incidence of newly acquired herpetic keratitis and to assess contributing factors. METHODS: The authors retrospectively studied the results of 2398 penetrating keratoplasties performed between 1980 and 1995. Three typical case histories are discussed. RESULTS: Of 2112 patients in whom the primary diagnosis was not related to HSV keratitis, 18 presented with epithelial herpetic keratitis in their corneal graft. The incidence of newly acquired herpetic keratitis after penetrating keratoplasty was 1.2 per 1000 person-years. In most cases, the infection occurred in the first 2 years after the transplantation. Most often, well-known reactivating stimuli could have caused the HSV infection. CONCLUSIONS: Herpes simplex virus keratitis may develop after penetrating keratoplasty even without a clinical history of HSV in the host. Thus, HSV should be considered in the differential diagnosis of a postpenetrating keratoplasty epithelial defect. The high incidence of this infection in the first 2 years after such surgery suggests a causal relation between corneal transplantation and the HSV infection.

Epidemiology of genital chlamydial infections in patients with chlamydial conjunctivitis; a retrospective study.

OBJECTIVE: To determine how often chlamydial conjunctivitis is accompanied by a genital chlamydial infection and if there is a correlation between the dominant hand and the eye first infected. METHODS: We retrospectively studied the records of 65 patients with chlamydial conjunctivitis who were referred to the Outpatient Department of Sexually Transmitted Diseases (STD) of the University Hospital Rotterdam by ophthalmologists of the Eye Hospital Rotterdam. The patients have recently been asked by letter if they were left- or right-handed. RESULTS: Twenty of the 37 men (54%) had a positive chlamydial urethral culture. Seventy per cent of these men had no genital symptoms. Eight of the 37 men (22%) had a non-specific urethritis (NSU). Twenty of the 27 women examined (74%) had a positive chlamydial cervical culture. Sixty per cent of these women had no genital symptoms. Eight women with a genital chlamydial infection also had another genital infection. Five women without a genital chlamydial infection had another genital infection. Two women had no genital infection at all. A correlation between the eye infected and left- or right-handedness of the patient could not be found. CONCLUSIONS: A considerable percentage of the patients with a chlamydial conjunctivitis had a concomitant genital chlamydial infection. The majority of them had no genital symptoms. Since patients with chlamydial conjunctivitis and/or their partners possibly have a concomitant genital chlamydial infection, we recommend referral of both patients and sexual partners to an STD clinic for routine examination and systemic treatment when indicated.

A retrospective study on the effectiveness of oral acyclovir to prevent herpes simplex recurrence in corneal grafts.

OBJECTIVE: A retrospective study of the effectiveness of prophylactic acyclovirn to prevent recurrent infections after penetrating keratoplasty for herpetic macula. METHODS: Follow-up data of 22 patients who where treated prophilactically with oral acyclovir (2 x 400 mg for the first three months after keratoplasy) and of 19 control patients were compared. All patients were operated between 1989-1991 after being free of recurrent Herpes simplex virus (HSV) infections for a minimal period of six months. Survival was defined as the probability of being free of HSV recurrence. RESULTS: The hazard ratio calculated for the data of a 24 month follow-up was 0.66 (95%Cl: 0.47, 3.8). Survival probabilities at six months were 0.95 for the prophylaxis and 0.74 for the control group (95%Cl of the difference: 0.07, 0.37); after 12 months these proportions were 0.72 and 0.54 respectively (95% Cl: -0.13, 0.47). CONCLUSIONS: In concordance with former studies we conclude that acyclovir may be effective as a prophylaxis in this category of patients. The probability of being free from recurrence was significantly different after six months but not after twelve, possibly indicating that the period of prophylaxis was too short.

Toxic keratopathy due to the accidental use of chlorhexidine, cetrimide and cialit.

Due to economical reasons some ophthalmologists are using an irrigating solution made by the hospital pharmacy instead of the commercially available solutions. These irrigating solutions come in bottles which are identical to the ones used for other solutions. During the last three years bottles were accidentally mixed up five times. Consequently, bottles containing solutions such as chlorhexidine, cetrimide, chlorhexidine/centrimide and cialit solutions were used during cataract surgery. This resulted in immediate corneal edema which, in its turn resulted in a bullous keratopathy. Four patients underwent a penetrating keratoplasty. In one patient the cornea was covered with a conjunctival flap. Light microscopy of the corneas included epithelial edema, loss of keratocytes, and a disrupted and sometimes absent endothelial cell layer.

Unusual deposits in the superficial corneal stroma following combined use of topical corticosteroid and beta-blocking medication.

Clinical observation of eight patients with superficial stromal precipitation of calcium phosphate is presented. In all cases the predisposing factors for the formation of these depositions were: epithelial defects and the combined use of topical dexamethasone phosphate or prednisolone phosphate with topical beta-blocking agents. In two patients the medication that gave rise to these precipitates was used without preservatives, suggesting that the medication itself and not the preservatives contribute to the deposits. Discontinuance of simultaneous administration of the steroids and beta-blocking agents prevented further formation of precipitates. The authors suggest an interaction between simultaneously given steroid and beta-blocking agents, giving rise to calcium phosphate precipitates when an epithelial defect is present which allows easy access to the superficial corneal stroma.

Deep corneal stromal opacities in long-term contact lens wear.

In 32 patients with long-term contact lens wear (up to 19 years), deep whitish opacities directly adjacent to Descemet's membrane were seen in the central part of the cornea. These opacities were seen in soft hydroxyethylmethacrylate (HEMA) as well as in hard (polymethylmethacrylate, PMMA) contact lens wear. These conditions could reduce visual acuity. When contact lens wear was discontinued or when the HEMA or PMMA lenses were replaced by gas-permeable rigid lenses, the lesions gradually diminished and resolved completely in most patients. One possible cause of these opacities is an allergic reaction to thimerosal. Another possible cause is chronic anoxia of the corneal stroma and endothelium. Endothelial cell density was not abnormal, but there was a marked polymegethism of the endothelium as a sign of endothelial stress.

Effects of disodium cromoglycate and beclomethasone dipropionate on the asthmatic response to allergen challenge II. Late response (LAR).

The protective effects of disodium cromoglycate (DSCG; Lomudal, Intal) and beclomethasone dipropionate (BDA; Aldecin, Becotide, Beclovent) on the late asthmatic response to allergen challenge (LAR) were investigated in 61 patients with allergic bronchial asthma. The 61 patients developed a total of 83 late asthmatic responses, 35 isolated late responses (ILAR), and 48 dual late responses (DLAR), which is a combination of an immediate response (IDLAR) and a late response (LDLAR). Disodium cromoglycate demonstrated significant protective effects on the LAR (P less than .01), however, the LDLAR as part of the DLAR was decreased by DSCG to a slightly higher degree than the ILAR. The BDA also showed significant protective effects on the LAR (P less than .01), but the ILAR was protected by BDA to a slightly higher degree than the LDLAR as part of the DLAR. The immediate asthmatic response as part of the DLAR was prevented by DSCG significantly (P less than .01) while the BDA was ineffective (P greater than .05). It can be concluded that both DSCG and BDA demonstrated significant effects on the LAR. It is suggested that DSCG should be used as a drug of the first choice to control bronchial asthma with an allergy component where the LAR plays a role. The BDA should be added temporarily at the beginning of the treatment of patients in whom the isolated late asthmatic response plays the predominant role, or of patients in whom the DSCG does not provide full control of the LAR during a certain period, eg, during the peak of the pollen season.(ABSTRACT TRUNCATED AT 250 WORDS)

Infectious crystalline keratopathy.

In seven patients white branched crystalline opacities, which grew very slowly, were seen in the corneal stroma. They were associated with very little inflammatory activity, so that the clinical picture at first did not suggest an infectious etiology. Pathological examination, however, demonstrated colonies of bacteria between intact corneal lamellae. On bacterial examination gram-positive commensals were mainly found. All the patients described so far were found to be taking corticosteroids regularly, sometimes in combination with antibiotics. The immunosuppression brought about by corticosteroids is probably an important factor in the development of these crystalline opacities. The therapy for this infectious crystalline keratopathy is difficult and lengthy. It consists of local bactericidal antibiotics and the lowest possible dosage of corticosteroids, if necessary combined with a partial lamellar keratectomy and removal of the affected corneal tissue by fraising.