CMV corneal endotheliitis after DMEK can mimic graft injection

This is the first report of cytomegalovirus (CMV) corneal endotheliitis after Descemet membrane endothelial keratoplasty (DMEK).

Study design

This retrospective interventional case series examined the presenting features, outcomes and treatment in 4 patients diagnosed with CMV corneal endotheliitis following DMEK. All keratoplasty surgeries were performed by a single surgeon in Singapore between 2014 and 2018. Of the 122 DMEK surgeries in the series, only 4 patients were diagnosed with CMV corneal endotheliitis; presentation occurred 5 to 15 weeks after DMEK.

Outcomes

All 4 cases presented with keratic precipitates and anterior uveitis. Raised IOP and corneal edema were present but variable. Two patients received delayed diagnosis and treatment because they were initially misdiagnosed with graft failure. Three cases achieved resolution with topical ganciclovir gel and oral valganciclovir. The remaining patient received IV ganciclovir and foscarnet but still did not respond. The patient was maintained on topical ganciclovir and spontaneously resolved after 3 months.

Limitations

This retrospective case series highlights the rare but important occurrence of CMV endotheliitis following corneal transplantation. Given the small sample size, this study could not determine the optimal treatment regime for this condition.

Clinical significance

It is important to recognize CMV corneal endotheliitis as a complication following DMEK surgery. Disease features at presentation may mimic graft rejection; topical steroid therapy may worsen the disease due to local immunosuppression. Anterior chamber paracentesis can be performed to assess for the presence of CMV, and the combination of topical and oral antivirals may help with disease resolution.