Immune Ring Formation Associated with Cytomegalovirus Endotheliitis

Abstract

We read with great interest the article “Immune Ring Formation Associated with Cytomegalovirus Endotheliitis,” by Chee and associates. 1 Chee S.P. Jap A. Immune ring formation associated with cytomegalovirus endotheliitis. Am J Ophthalmol. 2011; 152: 449-453 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar In their series of 72 cases of cytomegalovirus (CMV) infection, they found corneal immune rings (IR) in 3 CMV endotheliitis cases. Although the IR often is related to herpes simplex stromal keratitis, they suggested that their cases with IR were caused by the CMV infection. Their diagnosis was based on DNA of CMV detected in the aqueous by real-time polymerase chain reaction, not on the direct histopathologic evidence of CMV particles or antigen in the corneal tissue. CMV was detected in aqueous only; however, one can not rule out the possibility that the ring was caused by herpes simplex virus (HSV). In 2 of our corneal endotheliitis cases, DNA of both HSV and CMV were detected in the same eye, which suggested that HSV and CMV can coexist in corneal endotheliitis cases. Although their 3 cases with IR improved after the valganciclovir treatment, because valganciclovir also has an effect on HSV, 2 Field H.J. De Clercq E. Antiviral chemistry & chemotherapy's current antiviral agents FactFile (2nd ed.) DNA viruses. Antivir Chem Chemother. 2008; 19: 51-62 PubMed Google Scholar the possibility of HSV infection still can not be ruled out. Because HSV particles and antigen were detected in the IR of herpes simplex stromal keratitis, the results reported by Chee and associates will be more convincing after they have direct histopathologic evidence from their cases to prove the their assumption. 3 Meyers-Elliott R.H. Pettit T.H. Maxwell A. Viral antigens in the immune ring of herpes simplex stromal keratitis. Arch Ophthalmol. 1980; 98: 897-904 Crossref PubMed Scopus (62) Google Scholar Immune Ring Formation Associated With Cytomegalovirus EndotheliitisAmerican Journal of OphthalmologyVol. 152Issue 3PreviewTo describe immune ring (IR) formation as a manifestation of cytomegalovirus (CMV) endotheliitis. Full-Text PDF ReplyAmerican Journal of OphthalmologyVol. 154Issue 2PreviewWe thank Chiang and Tsai for their interest in our study. They suggest that the 3 cases of immune ring formation described in our study may have been a result of herpes simplex stromal keratitis rather than cytomegalovirus (CMV).1 We agree that it may be clinically difficult to distinguish between different viral entities; hence, testing for viral DNA is necessary. We adhere to a stringent clinical protocol in our uveitis clinic at the Singapore National Eye Centre in which every patient suspected of having viral uveitis initially undergoes aqueous analysis for herpes simplex virus, varicella zoster virus, and CMV by polymerase chain reaction, as stated in the Methods section of our article. Full-Text PDF