1. Role of HSV Infection in the Histopathology of Failed DSAEK
Authors:
Julia P. Shulman, MD; Mark Kropinak, MD; David C. Ritterband, MD; Henry D. Perry, MD; John A. Seedor, MD; Steven A. McCormick, MD; Tatyana Milman, MD
Authors have no financial interest

2. Purpose
To determine the role of HSV in graft failure by analyzing failed Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) lenticles with histopathology and immunohistochemistry.
To compare histopathology of HSV positive and HSV negative failed lenticles.

3. Methods
Retrospective, single-center, non-randomized consecutive series, in which 24 failed DSAEK lenticles from three surgeons were analyzed to establish the rate of HSV infection and lenticle histopathology.

4. Results The average patient age in this series was 75 (range, 56-90).
Indications for DSAEK included
Fuchs’ endothelial dystrophy (11)
Pseudophakic bullous keratopathy (7)
Failed graft (2)
Corneal decompensation after multiple previous surgeries (2)

5. Results 3 lenticles were found to be HSV positive
(3/24,13%) by immuno-histochemistry
none had a prior clinical history of HSV keratitis.
HSV positive failed lenticles
had a lower average endothelial cell count
were thinner than failed HSV negative lenticles.

6. Results Average ECC (cells/hpf) Lenticle Thickness (nm) HSV positive
1.65
425 +/- 156
HSV negative
2.25
/- 217
Table I. Comparison of average endothelial cell count (ECC) and lenticle thickness in HSV positive and negative lenticles

7. Results
Some degree of chronic stromal inflammation was associated with all lenticles irrespective of HSV status, and was not a significant parameter in identifying HSV positive lenticles.
HSV positive lenticles were associated with a greater degree of interface fibrosis as compared to HSV negative lenticles.

8. Results
Acute and chronic inflammation observed in a graft with HSV-1 immunoreactivity
Figure I

9. Conclusions
While the presence of HSV-1 antigens has been observed in one third of primary penetrating keratoplasty failures, it has not previously been documented in failed DSAEKs.
HSV may be a risk factor for lenticle dislocation though larger studies are needed to confirm the statistical significance of these observations.
The HSV positive lenticles were found to be thinner despite lower endothelial counts, suggesting that HSV infectivity may affect thickness in a mechanism not mediated through endothelial cell count and hydration.

10. References
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