Topical ganciclovir for prophylaxis of cytomegalovirus endotheliitis in endothelial keratoplasty

Abstract Body:

Purpose: To describe the presentation and management of two cases of DSEK with subsequent failure secondary to CMV infection and prophylaxis with topical ganciclovir to prevent repeat DMEK failure.

Study Design: Retrospective case series

Methods: A chart review was conducted for 2 patients (2 eyes) with DSEK failure secondary to CMV ocular infection confirmed by PCR of anterior chamber (AC) paracentesis sample.

Results: A 53 year old male (patient 1) and a 70 year old male (patient 2) received DSEK for decompensated cornea secondary to iritis and pseudophakic bullous keratopathy, respectively. Patient 1 was immunocompromised (on prednisone, etanercept, and methotrexate for psoriatic arthritis) while patient 2 was immunocompetent. Patient 1 had first graft failure at 21 months and patient 2 at 10 months. Initial clinical signs included inferior edema, keratic precipitates (KPs) and minimal anterior cellular reaction. Both failed to respond to topical steroid drops, and patient 2 had 3 subsequent failed DSEKs. AC paracentesis confirmed CMV DNA. They received oral valganciclovir for six weeks but both continued to have signs of inflammation and edema with repeat AC samples positive for CMV. They were then started on topical ganciclovir (0.15% ophthalmic gel). Repeat endothelial transplant (Descemet’s Membrane Endothelial Keratoplasty [DMEK]) was performed for both patients. They were restarted on topical ganciclovir 4 times a day after surgery as aqueous samples collected during transplant were positive for CMV. Both patients remain free of inflammation or failure on topical ganciclovir for 27 months (patient 1) and 20 months (patient 2) with uncorrected visual acuities of 20/25 and 20/40 respectively.

Conclusions: In cases of DSEK failure with multiple recurrences or history of ocular inflammation, CMV should be considered as a possible causative agent. For the first time in the literature, we demonstrate that long-term topical ganciclovir can be used to prevent recurrence of inflammation and subsequent graft failure in repeat keratoplasty — without the systemic side effects of systemic valganciclovir / foscarnet.