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Purpose To describe cases in which netarsudil ophthalmic solution 0.02% precipitated reversible, reticular cystic epithelial edema. Methods A retrospective case review at the Brooklyn Veteran's Association Hospital of patients with corneal stromal edema that were treated with netarsudil and subsequently developed cystic epithelial edema. Results Four male patients with a mean age of 72 ± 8.0 years developed a reticular, honeycomb-like pattern of epithelial edema located in the interpalpebral and inferior cornea. In 3 of 4 patients, epithelial edema arose within 1 month compared with 2 months in 1 patient. New epithelial cysts did not correlate with worsening central corneal thickness and best spectacle-corrected visual acuity in every patient, which was likely due to the location of the cysts. Two of 4 patients developed increased central corneal thickness with worsening best spectacle-corrected visual acuity. In comparison, 1 patient had improvement in both parameters, whereas 1 patient had no significant change. In all cases, there was resolution of the epithelial cysts after discontinuation of netarsudil. Conclusions Although rho-kinase inhibitors have been suggested to improve endothelial function, we have documented worsening epithelial cysts in a subset of patients with pre-existing corneal edema. These effects of netarsudil were transient and resolved after discontinuing treatment within 2 weeks in most patients. We hypothesize that the incidence of this adverse finding is more common than previously believed. Nevertheless, large-scale studies are needed to accurately report on the incidence and clinical significance of this novel finding.

A 43-year-old man developed acute corneal hydrops after laser in situ keratomileusis (LASIK). A persistently fluid-filled interface between the corneal flap and stroma (without flap dehiscence or wound leakage) did not respond to the conservative treatment. To avoid keratoplasty, the subflap fluid was drained by an air injection into the anterior chamber; the surgery also included suturing of the corneal flap and stroma. The corrected distance visual acuity improved rapidly after resolution of the fluid-filled interface and corneal stromal edema, and no leakage was observed. Thus, a minimally invasive surgery to drain the subflap fluid by an air injection was effective for treating a persistently fluid-filled interface in a case of acute corneal hydrops after LASIK.

Pseudophakic bullous keratopathy is characterized by corneal stromal edema with epithelial and subepithelial bullae due to cell loss and endothelial decompensation through trauma during cataract surgery. Patients present decreased vision, tearing, and pain caused by ruptured epithelial bullae. Cataract affects approximately 20 million people worldwide, and this complication can occur in 1 to 2% of the cataract surgeries. This study reviewed the bullous keratopathy etiopathogenesis and the clinical and surgical treatment available for this corneal disease.

Purpose: To evaluate the outcomes of implantation of an iris-claw intraocular lens (IC-IOL) in retropupillary position in aphakic patients. Methods: We conducted a prospective interventional study, including 36 aphakic eyes with inadequate capsular support. The postoperative examination included best-corrected visual acuity (BCVA), intraocular pressure (IOP) measurement, central corneal thickness (CCT), and anterior segment examination with emphasis on the anterior chamber reaction and shape of pupil. Follow-up was done for 3 months. Results: Thirty-six eyes of 34 patients, including 22 right eyes and 14 left eyes were included. Indications for surgery were complicated cataract surgery in 38.9% (n = 14), aphakia in 27.8% (n = 10), pseudophakic bullous keratopathy in 16.7% (n = 6), dislocated posterior chamber IOL (PCIOL) in 11.1% (n = 4), IC drop in 2.8% (n = 1), and subluxated PCIOL in 2.8% (n = 1). Postoperatively, the visual acuity improved by at least two lines in 32 (88.9%) and worsened in four (11.1%) eyes at the end of three months. Mean postoperative IOP at the end of the third month was 12.42 mmHg (standard deviation [SD] 2.57; range 11.55–13.29 mmHg). The mean postoperative CCT at the end of the third month was 542.42 microns (SD 13.77; range 537.76–547.07 microns). Sixteen eyes (44.4%) had horizontally oval pupil, eleven eyes (30.6%) had round pupil, and nine eyes (25%) had irregular pupil. Twenty-three eyes (63.9%) presented with significant anterior chamber reaction and seven eyes (19.4%) had corneal stromal edema on postoperative day 1. Conclusion: Our study demonstrated that retropupillary IC-IOL implantation in eyes without adequate capsular support is an effective and safe procedure with a good visual outcome and fewer complications.

PURPOSE To report a case of delayed spontaneous Descemet membrane (DM) tear after big-bubble Deep Anterior Lamellar Keratoplasty (DALK). METHODS Uneventful big-bubble DALK was performed on a 29-year-old patient with advanced keratoconus. No injury to DM was noted intraoperatively and in the first postoperative week. On examination after 1 month, the patient presented with tear and partial detachment of Descemet membrane (DMD). RESULTS Circumscribed eccentric stromal edema, but not DMD, partially resolved after a 3-month observational period. CONCLUSIONS A tear to DM and consecutive DMD may occur spontaneously after big-bubble DALK. Sutural traction and regressing corneal stromal edema may be etiologic factors.

Item does not contain fulltext A 48-year-old myopic patient with bilateral anterior chamber depth of 3.1 mm and endothelial cell density (ECD) of 2525 cells/mm(2) and 2638 cells/mm(2) preoperatively had bilateral implantation of an Artisan iris-fixated phakic intraocular lens (pIOL). Five years postoperatively, unilateral corneal stromal edema was seen in a circumscribed area overlying the temporal ridge of the pIOL in the right eye; the ECD was 1631 cells/mm(2) and the pachymetry, 586 microm. Explantation of the pIOL was refused by the patient. Seven years postoperatively, the ECD was 413 cells/mm(2) in the right eye and corneal decompensation occurred. The progressive unilateral endothelial loss was explained by excessive rubbing of the eyes because of chronic itching and an anterior shift of the pIOL over the 7 years as demonstrated by anterior optical coherence tomography.

Microbial keratitis caused by more than one microorganism is rare. It may occur as a coinfection or as a secondary infection superimposed with an existent microorganism.[1] Both infectious and immune mechanisms are implicated in microbial keratitis. Herein, we report an unusual clinical case of viral and fungal mixed infection. Written informed consent was obtained from the patient. A 31-year-old man complained of red left eye for 10 days; accompanied with eye pain, photophobia, and blurred vision for 7 days and exacerbated in the next 2 days. At the beginning, he visited a hospital in Beijing. Corneal smear and the scrapings culture results were negative. Then he was treated as a patient with viral keratitis. He used topical ganciclovir eye gel, interferon, levofloxacin, pranoprofen eye drops, deproteinized calf blood extract eye gel, and oral famciclovir tablets. Ocular manifestation was alleviated obviously according to the patient's description and medical record. At 3 days before, he visited our hospital, the patient suffered from heavy cold and recovered after he took over-the-counter cold medications. Unfortunately, he felt severe eye pain and photophobia for 2 days before he was referred to our hospital. He had neither trauma history nor wore contact lenses previously. The visual acuity of his right eye was 20/20. No significant abnormality was detected in the right eye. While the visual acuity of the left eye was counting finger in front of the eye and could not be corrected. The clinical manifestation was showed in the Figure 1a. Figure 1 (a) Gray infiltrate with irregular edges involved approximately 5 mm diameter of the cornea. Endothelial plaque, satellite lesions, and hypopyon appeared. (b) Corneal infiltrate and satellite lesions were confluent. (c) Corneal epithelium erosion and ... After the patient was admitted, a repeat corneal smear was performed, and the scrapings were sent for bacterial (aerobes/anaerobes), fungal, and Acanthamoeba cultures and tested for antibiotic sensitivity. Fungal hyphae and epithelium were found in corneal smear [Figure ​[Figure1g1g and ​and1h].1h]. However, cultures were negative. The patient was diagnosed with fungal keratitis and viral keratitis based on previous medical history, clinical manifestations, and corneal smear results. The procedure of treatment was divided into four stages. Rapid remission stage lasted approximately 1 week [Figure 1b]. Combined antifungal, antiviral, and anti-inflammatory therapy was administered, including 5% natamycin eye drops (q1h), ganciclovir eye gel (tid), pranoprofen eye drops (qid), tropicamide (a cycloplegic compound) eye drops (tid), and oral acyclovir tablets (400 mg, qid). Hypopyon disappeared 1 day after treatment, but fungi were persistent in corneal scrapings 4 days after treatment. Chronic lag stage lasted more than 2 weeks. The patient complained about eye pain at night. Severe mixed conjunctival congestion appeared. Corneal epithelium erosion enlarged, accompanied with sustained stromal edema and aqueous flares [Figure 1c]. The stromal infiltrate improved very slowly. We considered that the toxin released when the hyphae was broken and the toxicity related to topical eye drops, particularly 5% natamycin, may injure the ocular surface. Thus, we gradually reduced the dosage of natamycin from q2h to qid. Pranoprofen and tropicamide eye drops was terminated because of ocular surface defect side effects. Antiviral therapy was same. Ocular surface protections was added, such as artificial tears without preservatives, dextran 70 eye drops (qid), deproteinized calf blood extract eye gel (bid), and sodium chloride conjunctival sac wash (bid). Corneal scrapings did not contain fungi 16 days after the patient was admitted. Healing stage lasted approximately 1 week. Conjunctival congestion was still severe. Corneal epithelium defect and infiltrate were healing very slowly, accompanied with mild anterior chamber inflammation [Figure 1d]. The topical treatment of 5% natamycin and ganciclovir was completely withdrawn at the end of this stage. Reparation stage lasted 2 weeks. Corneal stromal edema and inflammation still existed. We carefully observed lesion development for 7 days without recrudescence even withdrew antifungal agent [Figure 1e]. Then topical corticosteroid 0.1% fluometholone eye drops (tid), tobramycin, and dexamethasone ointment (qon) was administered. Oral acyclovir tablets tapered slowly. Conjunctival congestion was alleviated. Corneal infiltrate gradually vanished. The anterior chamber was quiet. When the patient was discharged, the visual acuity of the left eye increased to 20/40 [Figure 1f]. The fungus is a kind of conditional pathogenic microorganism. In a normal conjunctival sac, the positive rate of fungal culture ranges from 2.9%[2] to 27.4%.[3] Fungal keratitis is the combined result of pathogen and host factors, such as long-term use of broad-spectrum antibiotics, dysbacteriosis in the conjunctival sac, or application of corticosteroids, leading to local hypoimmunity or corneal trauma cases. In general, patients exhibit ocular trauma history, particularly from contact with plants or wood. In the present case, the patient was a young, healthy office staff without trauma or systemic disease except colds. The corneal smear was negative for microorganism at his first consultation. Corneal ulceration was diagnosed and treated as viral keratitis. The diagnosis was based on empiric with the clinical manifestation and effective diagnostic treatments. After the patient was referred to our hospital, fungal hyphae were detected. A typical clinical manifestation of mycotic keratitis caused by filamentary fungi showed. It is extremely rare that fungi and virus affected cornea at the same time. Polymerase chain reaction is a sensitive diagnostic method to detect viruses. Unfortunately, we could not get viral sample laboratory test in etiologic diagnose. Considering the medical history and antiviral diagnostic treatment was effective on the 1st week after onset, we believed that viral keratitis existed and fungal keratitis might be a secondary infection caused by previous infection. Although the mechanism of mixed infection was hard to determine, we speculated the existed corneal ulcer might be the potential causes of subsequent fungal infection. Meanwhile, the antivirals and antibiotics application aggravated conjunctival sac dysbacteriosis. Immediate treatment using antifungal with antiviral medicines was necessary. However, the early rapid remission stage turned to the chronic lag stage after many eye drops were used. Why did the severe mixed conjunctival hyperemia, corneal edema, and anterior chamber inflammation persist? At first, we considered eye drops-related irritation. After, we reduced the administration frequency and provided ocular surface protections, the corneal epithelium started to heal, but stromal edema and inflammation persisted for 1 month. Then topical immunopathologic mechanism was considered. Stromal keratitis is immunoinflammatory in nature, and local immunosuppression with topical steroids, along with antiviral coverage, should be involved.[4] However, topical steroids not only reduce immune inflammation, but potentially provide conditions suitable for the growth of exogenous fungi and ocular commensals. We carefully observed the lesion development without natamycin and then administered topical corticosteroid. The proper use of corticosteroids for the treatment of fungal corneal infections has been continuously debated.[5] The topical steroid is not prohibited, but should be applied with extremely care. Ophthalmologists should be aware of the uncommon manifestations of keratitis and adjust treatment depending on a patient's condition. Financial support and sponsorship This study was supported by a grant from Tianjin Medical University Eye Institute science foundation (No. 15YKYJS003). Conflicts of interest There are no conflicts of interest.

PURPOSE Corneal endotheliitis causes endothelial decompensation and is associated with significant visual impairment. The goal of this article is to report a case of corneal endotheliitis associated with coxsackievirus A24 infection after cataract surgery in a patient who had no previous symptoms indicative of conjunctivitis. METHODS A 55-year-old man was admitted for cataract surgery when acute hemorrhagic conjunctivitis was prevalent. Because he did not show any signs of suspected conjunctivitis, the cataract surgery was performed. No intraoperative complications occurred, and he was discharged 1 day after the surgery. Three days later, he visited our clinic with complaints of ocular pain and decreased vision in the left eye. Slit-lamp examination showed corneal stromal edema and mild inflammatory reaction in the anterior chamber. On postoperative day 7, anterior chamber irrigation and viral culture from the aqueous humor sample were performed. RESULTS Coxsackievirus A24 was detected in the viral culture. Electron photomicroscopic examination with immunohistochemical staining confirmed the presence of viral antigen. CONCLUSIONS This is the first report of corneal endotheliitis caused by coxsackievirus A24 confirmed by viral antigen detection in the aqueous humor of an affected eye.

Corticosteroids seem to affect the functions of corneal endothelial cells directly in addition to their anti-inflammatory effect.A 69-year-old man presented with blurred vision in his left eye and decreased visual acuity in both eyes. He had received anterior-posterior radial keratotomy for myopia in both eyes 40 years earlier.Both eyes showed mild corneal stromal edema in the pupil area. We diagnosed the condition as corneal edema secondary to cell loss and dysfunction of corneal endothelium after surgery. One month later, the stromal edema was further advanced in the left eye. Corneal thickness had increased from the initial value of 619 microm to 631 microm, and corrected visual acuity had decreased from 0.5 to 0.06. There were no signs suggesting inflammatory reaction. The left eye was then treated with topical corticosteroid eyedrops and subconjunctival corticosteroid injection. Two months later, corneal thickness had decreased to 546 microm and visual acuity had improved to 0.5.This case shows that topical corticosteroids may be effective in treating corneal edema by producing an anti-inflammatory effect and possibly activating the endothelium.

BACKGROUND Toxic epidermal necrolysis (TEN) can lead to ocular surface scarring associated with pain, dry eye symptoms, and decreased visual acuity that often are difficult to treat. HISTORY AND SIGNS A 34-year-old woman was referred to our department two-years after TEN induced by lamotrigin (lamictal(R)). She was complaining of severe visual acuity loss, pain, and dry eye symptoms. Visual acuity was reduced to light perception in the right eye (RE) and to 0.2 in left eye (LE). Basal Schirmer test was 2 mm in RE and 3 mm in LE. With or without therapeutic contact lenses, the patient was experiencing severe discomfort requiring tear supplementation up to 50 - 80 times/day in both eyes. THERAPY AND OUTCOME A free autologous mucosal graft (3.5 x 2.0 cm) was transplanted from the lower lip into the upper RE fornix. Six months after surgery, with therapeutic contact lenses, the need for tear supplementation was markedly reduced to 3 - 4 times/day in RE while it remained unchanged in LE. In RE, slit-lamp examination revealed decreases in the corneal stromal edema and in the diameter of neo-vessels associated with an improvement of visual acuity (counting fingers at 30 cm). Basal Schirmer test values were unchanged. It has to be mentioned that the improvement observed after surgery was markedly dependent on wearing a therapeutic contact lens. CONCLUSIONS Free autologous buccal graft transplantation (with its presumably accessory salivary glands) in association with the use of a therapeutic contact lens can be an efficient approach to treat ocular complication following drug-induced TEN (Lyell's syndrome).

To report the case of a patient with unilateral corneal endotheliitis in which both cytomegalovirus (CMV) and human herpesvirus-6 (HHV6) DNA was identified in the aqueous humor. A 67-year-old man with corneal endotheliitis OD was referred to us for decreased visual acuity. Local corneal stromal edema, pigmented keratic precipitates, a coin-shaped lesion and minimal anterior chamber reaction were observed by slit-lamp biomicroscopy. Cells with owl’s eye appearance in the endothelial cell layer were observed by in vivo laser confocal microscopy. The patient had rheumatoid arthritis, which was treated by oral prednisolone and intravenous abatacept. Polymerase chain reaction analysis of aqueous humor samples detected both CMV and HHV6 DNA, but not other HHVs. Treatment with topical ganciclovir and systemic valganciclovir resulted in a clear cornea. A patient with corneal endotheliitis had both CMV and HHV6 DNA identified in the aqueous humor. Although both viruses were identified in this case, clinical manifestations resembled CMV corneal endotheliitis, and it was unclear whether HHV6 could affect the clinical course. Systemic abatacept and corticosteroid therapy might play a positive role in cases with both CMV and HHV6 DNA in this corneal endotheliitis.

Caso clínico: Varón de 62 años de edad con trasplante renal y tratamiento inmunosupresor que acude por disminución de la visión (20/100) en ojo izquierdo, edema corneal y presión intraocular de 46mmHg. Un mes después aparece queratitis dendrítica marginal inferior. El raspado corneal y la proteína C reactiva demuestran la presencia de un virus del herpes simple (HVS). Discusión: La epiteliopatía corneal autoinmunitaria o endotelitis idiopática corneal se caracteriza por edema corneal y precipitados queráticos. Se cree que el HVS podría ser secretado desde el trabeculum, inervado por el nervio trigémino, apoyado clínicamente por la progresión del edema estromal desde la periferia. Case report: A 62-year-old man with previous renal transplant and immunosuppressive treatment presented with decreased visual acuity (20/100) in his left eye, corneal oedema and intraocular pressure of 46mmHg. One month later an inferior marginal dendritic keratitis appeared. Corneal scraping and real-time polymerase chain reaction showed herpes simplex virus (HSV). Discussion: The autoimmune corneal endotheliopathy or acute idiopathic corneal endotheliitis is characterised by corneal stromal oedema and keratic precipitates. HSV might be secreted from the trabeculum, innervated by the trigeminal nerve. This hypothesis is supported by the clinical observation that the corneal stromal oedema usually starts from the periphery.

Three of four siblings born to parents with a history of heavy alcohol abuse had bilateral diffusely cloudy corneas at birth. These three siblings, who had mild systemic features of fetal alcohol syndrome, underwent corneal transplantations, and their specimens were examined by light and electron microscopy. Histologically, the alterations in Bowman's layer ranged from thickening to total loss. There were varying degrees of corneal stromal edema. The unique pathologic feature in the corneas was the anomaly of the anterior banded zone of Descemet's membrane, which was either absent, poorly formed, or thinned in the central and peripheral cornea. The corneal endothelium was attenuated or multilayered. The diffuse clouding and the range of histologic abnormalities in the corneas might be related to the maternal alcohol abuse.

Rhabdophis tigrinus is a common colubrid snake that can be found in an extensive geographical region in East Asia. It consists of two subspecies: R.t. tigrinus (yamakagashi) and R.t. formosanus (Taiwan tiger keelback). R. tigrinus possesses two different sets of poisonous glands: the Duvernoy's glands in the maxilla, and the nuchal glands in the dorsal skin of the neck. We report the first case in current English literature of toxin ophthalmia caused by the nuchal gland secretion of R.t. formosanus. The patient was a 40-year-old man whose right eye was sprayed by the nuchal gland fluid of R.t. formosanus. He presented with symptoms of foreign body sensation, progressive burning pain, and blurred vision. Ophthalmologic examination revealed diffuse superficial punctate keratitis, corneal stromal edema with Descemet folds, and conjunctival congestion. The patient responded well to topical treatment with a corticosteroid, antihistamine, and antibiotic, and had a favorable clinical course and outcome.

Purpose To report a series of severe corneal changes following intravitreal injection of bevacizumab (Avastin) for age-related macular degeneration. Design Retrospective noncomparative case series. Methods The authors retrospectively reviewed the corneal changes that developed after the procedure in 1200 (460 patients) intravitreal injections of bevacizumab. Results Five significant corneal changes (1.1%) occurred in these patients within the 1st postinjection week. The severe corneal changes included corneal infiltrative keratitis (n = 2) and corneal stromal edema and descemet folds (n = 3). The findings depended on clinical examination and biomicroscopic and confocal evaluation. In terms of causality assessment, no rechallenge was possible. The appropriate treatment was applied and recovery was achieved in all patients during the follow-up period. Conclusions Intravitreal injection of bevacizumab may cause corneal changes. The safety and effects of bevacizumab on the cornea should be evaluated in detail.

Purpose Human corneas with or without stromal edema were examined by second harmonic generation (SHG) imaging microscopy to characterize stromal collagen organization. Methods Tissue buttons from 31 corneas with stromal edema and 8 normal corneas were fixed, and 3-mm(2) blocks were cut and stained with phalloidin, to visualize the cytoskeleton. The blocks were examined by SHG imaging with a laser confocal microscope and a mode-locked titanium:sapphire femtosecond laser. Samples were scanned to a depth of 150 microm from the surface of Bowman's layer, and SHG forward- and backscatter signals were collected. Phalloidin staining was detected by conventional laser confocal microscopy. The three-dimensional structure of the anterior segment of the cornea was reconstructed from stacked SHG images. Results Three-dimensional reconstruction of SHG signals showed adherence of interwoven collagen lamellae in the anterior stroma to Bowman's layer in both normal and edematous corneas. Abnormal SHG signals at the level of Bowman's layer were observed in edematous corneas; three-dimensional images revealed that these signals were actually localized above Bowman's layer and were indicative of subepithelial fibrosis. Phalloidin staining showed transdifferentiation of stromal cells into fibroblastic cells in edematous corneas. The incidence of subepithelial fibrosis or of fibroblastic cells increased beginning 12 months after the onset of clinical stromal edema. Conclusions SHG imaging of the anterior segment of edematous corneas revealed a normal appearance of interwoven collagen lamellae in the anterior stroma. The development of subepithelial fibrosis beginning 12 months after the onset of edema suggests that stromal edema may be a progressive disease.

Purpose To describe a patient with cone dystrophy who presented with acute hydrops and perforation, leading to the diagnosis of keratoconus. Methods Case report and literature review. Results A 21 -year-old male patient with a history of cone dystrophy presented with a flat anterior chamber, diffuse corneal stromal edema with an intrastromal cleft, and ruptured Descemet membrane, findings consistent with acute hydrops with corneal perforation. After bandage contact lens placement and instillation of a cycloplegic agent, the anterior chamber reformed within 24 hours. Over the next week, conservative management with a bandage lens, pressure patching, topical fluoroquinolone antibiotic, and topical cycloplegic led to the reformation and maintenance of anterior chamber stability. Corneal topography of the unaffected eye showed global corneal thinning and steep sim K readings suspicious for early keratoconus. Conclusions Although the association between keratoconus and cone dystrophy is extremely rare, our patient's vision-threatening complication of acute hydrops with corneal perforation highlights the importance of corneal evaluation including topography in cone dystrophy. Conservative management was successful in the restoration of anatomic integrity in this situation.

Purpose To investigate clinical manifestations and response to antiviral therapy of 8 patients with cytomegalovirus (CMV)-induced corneal endotheliitis who were diagnosed and treated at 2 university hospitals in Japan. Design Retrospective, consecutive, multicenter case series. Participants Eight eyes of 8 patients diagnosed with active CMV corneal endotheliitis at Kyoto Prefectural University of Medicine and Ehime University School of Medicine. The diagnosis was made based on the detection by polymerase chain reaction assay of CMV, but not herpes simplex virus (HSV) and varicella zoster virus (VZV) DNA, in the aqueous humor from the affected eye. Methods Retrospective review of the clinical manifestations and responses to antiviral treatment. Main Outcome Measures Patient profiles, including duration of corneal endotheliitis, systemic disease, intraocular pressure, and clinical manifestation of anterior and posterior segments. The clinical response to systemic and topical antiviral treatment was evaluated by slit-lamp examination. Corneal endothelial density was examined by specular microscopy. Results The average observation period after CMV detection was 10.4 months (range, 2–24 months). None of the patients had systemic immunodeficiency. Corneal manifestations included linear keratic precipitates associated with multiple coin-shaped lesions and local corneal stromal edema. Of the 8 patients, 4 had undergone penetrating corneal transplantation. Systemic ganciclovir therapy was used in 7 patients, and in 1 patient, valacyclovir was administered, with the corneal endotheliitis responding quickly to the early administration of galovir. At the final examination, 6 eyes had a clear cornea, but 2 eyes had bullous keratopathy. Conclusions Besides HSV and VZV, CMV must be considered as an etiologic agent in patients with corneal endotheliitis. Cytomegalovirus corneal endotheliitis may be a newly identified clinical entity of reactivated CMV in the anterior chamber of individuals free of accompanying systemic symptoms.

Purpose. To report bilateral corneal endotheliitis caused by a vesicular virus (family Rhabdoviridae). Methods. Case report of a 49-year-old man with a complaint of sudden onset of decreased vision in both eyes had diffuse corneal stromal edema with extensive folds in Descemet's membrane and was diagnosed as having bilateral viral endotheliitis. Virologic investigations were performed using aqueous humor from the right eye. Results. An ether- and chloroform-sensitive cytopathic agent was isolated in Vero and BHK-21 cell lines from the aqueous humor. It was identified as a vesicular virus belonging to the family Rhabdoviridae by electron microscopy. Neutralizing antibody was demonstrated at a titer greater than 1 in 4,096 dilutions in the convalescent serum. Neurologic complications included loss of hearing and postinfectious polyradiculopathy affecting both lower limbs. Best-corrected visual acuity was 20/120 OD and 20/20 OS. Six months later, he developed glaucoma in the right eye. Trabeculectomy with intraoperative application of 5-fluorouracil was performed. Conclusion. This is the first report of bilateral endotheliitis caused by a vesicular virus and confirmed by virus isolation from the aqueous humor of the affected eye.

THE NEW ENGLAND JOURNAL OF MEDICINE Treatment of Severe Ocular-Surface Disorders With Corneal Epithelial Stem-Cell Transplantation Kazuo Tsubota, MD; Yoshiyuki Satake, MD; Minako Kaido, MD; Naoshi Shinozaki, MS; Shigeto Shimmura, MD; Hiroko Bissen-Miyajima, MD; Jun Shimazaki, MD Background Conditions that destroy the limbal area of the peripheral cornea, such as the Stevens-Johnson syndrome, ocular pemphigoid, and chemical and thermal injuries, can deplete stem cells of the corneal epithelium. The result is scarring and opacification of the normally clear cornea. Standard corneal transplantation cannot treat this form of functional blindness. Methods We performed and evaluated 70 transplantations of corneal epithelial stem cells from cadaveric eyes into 43 eyes of 39 patients with severe ocular-surface disorders and limbal dysfunction. Medical treatment had failed in all patients. The patients had a mean preoperative visual acuity of 0.004 (only being able to count the number of fingers presented by the examiner) in the affected eyes, which satisfies the criteria for legal blindness in most countries. In 28 eyes, we also performed standard corneal transplantation. Stem-cell transplantations were performed as many as four times on 1 eye if the initial results were not satisfactory; 19 eyes had multiple transplantations. Patients were followed for at least one year after transplantation. Results A mean of 1163 days after stem-cell transplantation, 22 of the 43 eyes (51 percent) had corneal epithelialization; of the 22 eyes, 7 eyes had corneal stromal edema and 15 eyes had clear corneas. Mean visual acuity improved from 0.004 to 0.02 (vision sufficient to distinguish the largest symbol on the visual-acuity chart from a distance of 1 m) (P Conclusions Transplantation of corneal epithelial stem cells can restore useful vision in some patients with severe ocular-surface disorders. N Engl J Med. 1999;340:1697-1703

PURPOSE: To report a case with corneal endotheliitis and idiopathic sudden sensorineural hearing loss, in which herpes simplex virus type 1 DNA was demonstrated in the trabeculum and the aqueous humor by polymerase chain reaction. DESIGN: Interventional case report. METHODS: A 60-year-old man presented with corneal stromal edema in the right eye and sudden bilateral sensorineural hearing loss. The trabeculum excised during trabeculectomy and the aqueous humor were examined for the presence of herpes simplex virus type 1 DNA by polymerase chain reaction. RESULTS: Polymerase chain reaction demonstrated herpes simplex virus type 1 DNA in the aqueous humor and the trabeculum. CONCLUSION: Herpes simplex virus type 1 may cause corneal endotheliitis and idiopathic sudden sensorineural hearing loss simultaneously.

A 56-year-old man developed idiopathic corneal endotheliopathy. The lesion consisted of severe stromal edema at the lower half of the cornea along with a number of associated keratic precipitates and steadily progressed to the upper half of the cornea. By polymerase chain reaction, herpes simplex virus DNA was demonstrated in the aqueous humor of this patient. Corneal stromal edema was resolved in response to treatment with topically applied and systemic acyclovir. Herpes simplex virus DNA was repeatedly demonstrated in the aqueous humor when the endothelial lesion recurred later. This evidence strongly indicates that this unique endothelial disorder is of viral origin.

PURPOSE: To report an eye with corneal endotheliitis and increased intraocular pressure in which the trabeculum demonstrated immunoreactivity for herpes simplex virus. METHOD: Case report. A 62-year-old man presented with increased intraocular pressure, keratic precipitates, and corneal stromal edema in his left eye. The tissue excised during trabeculectomy was immunohistochemically examined for herpetic viruses. RESULT: Immunoreactivity for herpes simplex virus was identified in the trabeculum. CONCLUSION: Herpes simplex virus may cause trabeculitis and increased intraocular pressure in patients with corneal endotheliitis.

Purpose To determine whether annular keratotomy can relieve pain associated with bullous keratopathy. Methods Three patients with painful bullous keratopathy and poor visual potential underwent partial-thickness (0.30 to 0.42 mm) trephination of the cornea under local anesthesia. Results All patients reported an absence of pain and foreign body sensation during an average follow-up interval of six months. The surgical procedure was uncomplicated; however, two eyes developed increased central corneal stromal edema. Conclusions Annular keratotomy appears to be a relatively safe and simple surgical procedure that may be useful in managing pain in eyes with painful cornea edema and poor visual potential.

Seven patients presenting with acute corneal stromal edema without prior surgery, trauma, ocular disease or known exposure to noxious agents are reported. One patient had a severe iridocyclitis; two others subsequently developed herpetic keratouveitis. Four cases, however, were unassociated with other known ocular disease. All four of these patients exhibited keratic precipitates and displayed minimal or no flare and cells in the anterior chamber, although the latter was largely obscured by the corneal edema. In each of these four instances, the inflammation and corneal edema resolved following topical corticosteroid therapy. In two of the four cases, both children, antibody to Herpes simplex virus could not be identified. We suggest that, in patients without known prior corneal disease or trauma, acute diffuse corneal stroma edema may stem from severe iridocyclitis or a primary endotheliitis due either to herpetic infection, the recently described presumed autoimmune corneal endotheliopathy, or a condition which we herein designate acute idiopathic corneal endotheliitis.

Corneal edema occurring in the congenital rubella syndrome can result from coexistent glaucoma or develop in the absence of an elevated intraocular pressure. We examined a 36-week-old female infant with documented congenital rubella syndrome who had bilateral corneal stromal edema without attendant congenital glaucoma. Histopathologic examination of the cornea revealed absent Descemet's membrane, deep interstitial keratitis, stromal corneal swelling, and deranged, focally absent endothelial cells. A viral infiltration of endothelium is postulated as the mechanism of the corneal edema and keratitis.

Background Surgeons may be unaware of the ability of plant toxins to cause corneal damage. Therefore, corneal damage following intraocular surgery due to plant toxins may be misdiagnosed as postoperative infection. Case presentation A 74-year-old man presented with hyperemia and reduced visual acuity in both eyes 6 weeks after uneventful cataract surgery. We observed extensive hyperemia and corneal stromal edema with Descemet’s folds in both eyes. After obtaining a detailed patient history, we diagnosed plant toxin-induced corneal edema due to Asclepias physocarpa, which can induce corneal edema by inhibiting the Na+/K+ ATPase activity of the corneal endothelium. Antimicrobial and steroid eye drops and an oral steroid were prescribed accordingly. Symptons began to improve on day 3 and had almost completely resolved by day 6. At 1 month, the patient had fully recovered without any sequelae. Conclusion The correct diagnosis was possible in the present case as symptoms were bilateral and the patient was able to report his potential exposure to plant toxins. However, if the symptoms had been unilateral and the patient had been unaware of these toxins, he may have undergone unnecessary surgical interventions to treat non-existent postoperative endophthalmitis.