Herpetic Keratitis Following Corneal Crosslinking for Keratoconus: A Case Series

Figures & data

Table 1 Patients’ Demographic and Clinical Information at the Initial Evaluation Before Corneal Crosslinking Surgery

Items	Patient 1	Patient 2	Patient 3	Patient 4
Gender	Male	Female	Male	Female
Age	29	27	14	16
History of keratoconus diagnosis	11 years for both eyes	5 months for both eyes	1 year for both eyes	1 year for both eyes
Signs of keratoconus on slit lamp	Vogt line, Fleischer ring, and Munson sign on both eyes	Vogt line, Fleischer ring, and Munson sign on both eyes	Vogt line, Fleischer ring, and Munson sign on both eyes	Vogt line, Fleischer ring, and Munson sign on both eyes
History of RGP use	Yes	No	No	No
BCVA	OD 0.4	OD 1.0	OD 1.0	OD 0.8
	OS 0.9	OS 0.8	OS 0.2	OS 0.4
Manifest optometry	OD: −9.00 SD/ −6.00 CD*45°	OD: 0.00 SD/ −8.00 CD*180°	OD: 0.00 SD/ −2.00 CD*180°	OD: −4.00 SD/ −0.75 CD*10°
	OS: −5.00 SD/ 0.00 CD	OS: −0.50 SD/ −12.00 CD*180°	OS: −4.00 SD/ −2.00 CD* 90°	OS: −6.00 SD/ −3.00 CD*165°
Intraocular pressure (mmHg)	OD 8.8	OD 15.2	OD 13.5	OD 10.1
	OS 12.3	OS 13.9	OS 11.0	OS 9.2
Central Corneal Thickness (μm)	OD 401	OD 503	OD 429	OD 460
	OS 484	OS 475	OS 395	OS 433
Corneal topography (OD)	K1 51.6	K1 43.2	K1 44.5	K1 45.6
	K2 60.2	K2 49.9	K2 49.6	K2 46.5
	Kmax 66.2	Kmax 53.1	Kmax 55.9	Kmax 51.8
Corneal topography (OS)	K1 43.6	K1 46.2	K1 48.9	K1 49.3
	K2 48.2	K2 57.6	K2 54.9	K2 52.0
	Kmax 52.1	Kmax 67.3	Kmax 64.6	Kmax 58.3
Corneal endothelium density (cells/mm^2)	OD 2984	OD 3101	OD 3169	OD 3113
	OS 2946	OS 2766	OS 2897	OS 3157
Schirmer’s test (mm)	OU >15	OD >15	OD 13	OU >15
		OS >12	OS 8
Tear breakup time (s)	OU >10	OU >10	OU >10	OU >10
Corneal fluorescein staining score	OU 0	OU 0	OD 1	OU 0
			OS 0
Serum anti-viral antibody tests
Anti-HSV I/II IgM	Negative	Negative	N.A.	Negative
Anti-HSV I/II IgG	Positive	Negative	N.A.	Positive
Anti-CMV I/II IgM	Negative	Negative	N.A.	Negative
Anti-CMV I/II IgG	Positive	Positive	N.A.	Positive
History of previous Ocular herpetic diseases	No	No	No	No
History of systemic diseases	No	No	No	No
History of eye trauma or surgery	No	No	No	No
Surgical eye (s)	OD	OS	Both	OS

Abbreviations: OD, right eye; OS, left eye; OU, both eyes; SD, spherical diopter; CD, cylindrical diopter; HSV, herpes simplex virus; BCVA, best corrected visual acuity; RGP, right gas-permeable lens; N.A., not available.

Table 2 Summary of Surgical Details and Post-Operational Management

Items	Patient 1	Patient 2	Patient 3	Patient 4
Surgical eyes	OD	OS	OU	OS
Radius of deepithelized area	9mm	9mm	9 mm	9 mm
Power of UVA	30 mW/cm^2	30 mW/cm^2	30 mW/cm^2	30 mW/cm^2
UVA application time	4 min	4 min	4 min	4 min
Total energy	7.2 J	7.2 J	7.2 J	7.2 J
Special operation	With a 50 um Lenticule on the corneal surface	No	With a 50 um Lenticule on the corneal surface	No
Post-operational drugs	Topical levofloxacin and fluorometholone	Topical levofloxacin and fluorometholone	Topical levofloxacin and fluorometholone	Topical levofloxacin and fluorometholone

Abbreviations: OD, right eye; OS, left eye; OU, both eyes; UVA, ultraviolet A.

Table 3 Summary of Clinical Manifestations of Patients Diagnosed with Herpetic Keratitis After Corneal Crosslinking (CXL)

Items	Patient 1	Patient 2	Patient 3	Patient 4
Onset time	3 days after CXL	1 week after CXL	1 month after CXL	3 days after CXL
Chief symptoms	Vision blurring	Vision blurring	None	None
Clinical signs at initial visit	Multiple punctate infiltrations in the stromal of pericentral region	Corneal opacity and stromal edema located at pericentral corneal	Corneal opacity and stromal edema	Multiple punctate stromal infiltrations in the central cornea
Treatment	Topical ganciclovir (QID) and oral acyclovir (200mg, QID) Topical tobramycin and dexamethasone (QID) for 3 days, replaced by fluorometholone (QID) Topical deproteinized calf serum (QID)	Topical ganciclovir (QID) and oral acyclovir (200mg, QID) Topical prednisolone (QID) Topical deproteinized calf serum (QID)	Topical ganciclovir (QID) and oral acyclovir (200mg, QID) Topical prednisolone (QID) Topical deproteinized calf serum (QID)	Topical ganciclovir (QID) and oral acyclovir (200mg, QID) Topical prednisolone (QID) Topical deproteinized calf serum (QID)
Follow up and prognosis	1 weeks, under control	2 weeks, under control	2 months, much better but still had stromal edema	1 week, almost cured
Clinical signs at last visit	Corneal nebula	Corneal nebula	Corneal macula	Corneal nebula

Abbreviations: CXL, corneal crosslinking; QID, four times daily; BID, two times daily.

Figure 1 Initial slit lamp examination of the involved eyes. (A) patient 1 presented with multiple punctate infiltrations in the stromal of the pericentral corneal and moderate conjunctival injection 3 days after surgery; (B) patient 2 presented with corneal stromal edema and opacity 1 week after surgery; (C) patient 3 presented with corneal opacity and stromal edema 1 month after surgery; (D) patient 4 presented with multiple punctate infiltrations in the stromal of the pericentral corneal 3 days after surgery.

Figure 2 Slit lamp examination of the involved eyes at the last follow-up visit. (A) patient 1, 1 week after treatment; (B) patient 2, 2 weeks after treatment; (C) patient 3, 2 months after treatment; (D) patient 4, 1 week after treatment.