Cytomegalovirus Corneal Endotheliitis Mimicking Graft Rejection After Corneal Transplantation

Abstract

Purpose: Cytomegalovirus (CMV) corneal endotheliitis is an underrecognized postoperative complication of corneal transplantation that closely resembles allograft rejection, often leading to delayed diagnosis and treatment. This study explored its clinical presentations, diagnostic challenges, treatment strategies, and long-term outcomes. Methods: A retrospective case series of nine patients (10 eyes) diagnosed with post-keratoplasty CMV endotheliitis at Ramathibodi Hospital, Bangkok, Thailand. Clinical features, diagnostic findings, treatment regimens, and outcomes were analyzed. A literature review was conducted to contextualize findings within previously reported cases. Results: The mean age at presentation was 65.4 ± 17.9 years, with a slight female predominance (55.6%). Seven out of 10 eyes were initially misdiagnosed with endothelial graft rejection. Common clinical findings were medium-to-large pigmented keratic precipitates (KPs) (80%) and mild anterior chamber inflammation (100%). The hallmark coin-shaped KPs were observed in only 20% of cases at initial presentation. CMV DNA was detected in all patients via aqueous humor polymerase chain reaction (PCR), with one case of possible Epstein-Barr virus co-infection. Treatment with systemic and/or topical ganciclovir led to clinical improvement; however, recurrence was common, with 85.7% of eyes on low-dose topical ganciclovir maintenance experiencing relapse. In contrast, higher-dose maintenance therapy was associated with a lower recurrence rate. Conclusions: Post-keratoplasty CMV endotheliitis can be misdiagnosed as graft rejection, delaying appropriate treatment. Early detection through heightened awareness and PCR testing is critical for timely intervention. Higher-dose topical ganciclovir maintenance therapy may be more effective in reducing recurrence, though long-term monitoring remains crucial for optimal outcomes.