Topical ganciclovir treatment in patients with cytomegalovirus endotheliitis receiving penetrating keratoplasty

Background: To report seven cases diagnosed as cytomegalovirus endotheliitis and treated with topical 2% ganciclovir following penetrating keratoplasty. Design: A retrospectively comparative case series. Participants: A retrospective interventional case series, including seven eyes of seven patients with cytomegalovirus endotheliitis after penetrating keratoplasty. Methods: Clinical and immunological characteristics were studied in seven penetrating keratoplasty cases with positive quantitative polymerase chain reaction results for cytomegalovirus DNA from aqueous taps and treated with topical 2% ganciclovir. Main Outcome Measures: Clinical features and responses to topical 2% ganciclovir. Results: Seven immunocompetent patients experienced acute anterior inflammation with graft oedema and pigmented keratic precipitates after penetrating keratoplasty. Their immunological profiles showed immunoglobulin G cytomegalovirus (+) and immunoglobulin M cytomegalovirus (-) in all cases. Topical 2% ganciclovir was prescribed every 2 to 3h daily as induction therapy and every 4h as long-term maintenance therapy. All cases had undetectable cytomegalovirus DNA after follow-up aqueous taps. Topical 2% ganciclovir preserved endothelium of cytomegalovirus-infected grafts at early stage and also provided a steady anticytomegalovirus environment for further regrafting in failed grafts at late stage. Acute inflammation reactivated in two cases and was suppressible by steroid under topical ganciclovir. No delayed re-epithelialization and any toxicity were observed. To date, no case treated in this way had displayed cytomegalovirus recurrence. Conclusions: Continuous topical 2% ganciclovir and a topical steroid adjusted by anterior inflammation are suggested after penetrating keratoplasty in all cases with cytomegalovirus endotheliitis to prevent cytomegalovirus recurrence. ? 2012 The Authors. Clinical and Experimental Ophthalmology ? 2012 Royal Australian and New Zealand College of Ophthalmologists.