When Immunotherapy And Herpetic Infection Collide: The Challenging Postoperative Course Of A Patient With Keratoconus Undergone Deep Anterior Lamellar Keratoplasty

To report the challenging postoperative case of a young patient affected by autoimmune
disease undergone uneventful deep anterior lamellar keratoplasty (DALK) for the treatment of
keratoconus.

Despite the eye is traditionally considered as an “immune privilege” site, the immune system is known to be either directly or indirectly implicated in a large array of ocular pathologies including, but not limited to infectious keratitis and corneal allograft rejection following transplantation.

A 25-year-old female patient affected by juvenile idiopathic arthritis treated with oral
methotrexate underwent DALK procedure for keratoconus. The surgery was uneventful and the
early postoperative course regular. Twenty months postoperatively, the patient complained of acute
onset of redness, photophobia, and blurred vision. Slit-lamp examination showed graft edema with
corneal neovascularization suggesting the diagnosis of immune stromal rejection. Dexamethasone
0.1% eye drops were prescribed every 2 hours. One month after, slit lamp examination showed a
rush of dendritic lesions suggestive of herpetic keratitis confirmed by polymerase chain reaction.
Due to the absence of clinical improvement after months of targeted treatment, oral methotrexate
was interrupted and ocular therapy was maintained unchanged. After one week, clinical picture
started improving, reaching a complete resolution few weeks later.

Strict follow-up programme is indicated in patients with active autoimmune disease
undergoing keratoplasty. Immunosuppressive treatment should be taken into account when targeted
therapies for herpetic keratitis do not work properly.