Cytomegalovirus as a Cause of Recurrent Corneal Endotheliitis in the Canadian Population: A Case Series
Authors: William M. Trask, Jamie Bhamra. Section of Ophthalmology, University of Calgary.
Author Disclosure Block: W.M. Trask: None. J. Bhamra: None.
Title: Cytomegalovirus as a Cause of Recurrent Corneal Endotheliitis in the Canadian Population: A Case Series
Purpose: To characterize the clinical manifestations, response to low dose systemic antiviral treatment and longterm visual outcomes of cytomegalovirus endotheliitis in a Canadian population.
Study Design: Retrospective case series encompassing nine eyes of seven patients with corneal endotheliitis.
Methods: A retrospective review of all patients presenting with corneal endotheliitis to one corneal surgeon was completed. Patients underwent anterior chamber biopsies with positive cytomegalovirus PCR. Patients with evidence of viral coinfection (HSV, VZV) were excluded from this series. All patients received systemic valganciclovir at therapeutic dosing for a minimum of 3 months, with subsequent titration at treating surgeon's discretion to establish long-term subtherapeutic maintenance dose. Primary outcomes included visual acuity, intraocular pressure control, medication dependence and corneal status.
Results: Nine eyes of seven patients were identified; the average follow-up was 76.4 ± 11.8 months. Two patients had bilateral disease. Corneal manifestations included linear, disciform and circinate patterns of endotheliitis. Best corrected visual acuity improved from mean LogMAR of 0.48 ± 0.19 at presentation to LogMAR 0.24 ± 0.11 at last followup. Intraocular pressure decreased from a peak of 35 ± 3.1 mmHg to 14.2 ± 4.3 mmHg. Ocular hypotensive medications were reduced from 2.6 ± 0.45 to 0.89 ± 0.29. Two eyes required endothelial transplantation. Valganciclovir therapy was well tolerated by all patients; at time of last followup, all subjects were stable on low dose valganciclovir at an average dose of 1395mg per week.
Conclusions: Cytomegalovirus is a rare but clinically significant cause of corneal endotheliitis, recurrent anterior uveitis, and corneal decompensation in the Canadian population that must be considered even in the immunocompetent population. This series is the first to report CMV endotheliitis in a North American study base, and confirms a similar pattern of clinical features to that seen in existing East Asian literature. Our results support prior findings that this entity responds robustly to oral valganciclovir, and demonstrate for the first time the efficacy of chronic low dose systemic antiviral maintenance therapy for the longterm management of this condition.