Mooren潰瘍の治療中にCMV角膜内皮炎を発症した2例

Two cases of cytomegalovirus corneal endotheliitis during treatment of Mooren's ulcer

要約　目的：Mooren潰瘍の治療中にサイトメガロウイルス（CMV）角膜内皮炎を生じた2例の報告。

症例：症例1は64歳の男性。両眼のMooren潰瘍の表層角膜移植術後で10年以上加療中であったが，2016年に外傷による右眼の眼球破裂で当科を紹介され，手術加療を行った。術後より右眼耳側に新たな周辺部角膜潰瘍が生じ，ステロイドおよび免疫抑制薬の点眼・内服で軽快した。2017年に左眼の視力低下と周辺部角膜潰瘍進行のため，表層角膜移植術および水晶体再建術を施行したが，術後より角膜実質浮腫と角膜後面沈着物が出現し，遷延した。眼圧は点眼・内服下で10mmHg台であった。左眼の前房水PCR検査でCMV陽性であり，ガンシクロビル点眼とバルガンシクロビル塩酸塩の内服を開始した。角膜浮腫は改善せず，2019年2月に全層角膜移植術を施行した。症例2は73歳の男性。2018年より左眼のMooren潰瘍の診断でステロイド内服および免疫抑制薬点眼で加療中であったが，角膜実質浮腫・前房炎症・角膜後面沈着物・眼圧上昇を認め，当科へ紹介となった。初診時の左眼の前房水PCR検査でCMV陽性であり，ガンシクロビル点眼を開始した。前房炎症は改善したが，上方強膜の菲薄化が徐々に進行し，2019年3月に保存強角膜移植術および羊膜移植術を施行した。

結論：Mooren潰瘍の治療中にCMV角膜内皮炎を生じた2例を経験した。ステロイドや免疫抑制薬投与中にCMV活性化を引き起こす可能性も示された。

Abstract　Purpose：To report of two cases of cytomegalovirus（CMV）corneal endotheliitis during treatment of Mooren's ulcer.

Case：Case 1 was a 64-year-old man, who had been treated for more than 10 years with the diagnosis of Mooren's ulcer after lamellar keratopsy in both eyes. He was referred to our department in 2016 due to trauma in the right eye, and treated by surgery. In the postoperative period a new peripheral corneal ulcer developed in the right eye and was relieved by instillation and administration of steroids and immunosuppressants. In 2017, lamellar keratoplasty and cataract surgery were performed successfully for left visual acuity loss and peripheral corneal ulcer progression. Corneal edema and keratic precipitates appeared after surgery. PCR examination using an aqueous sample showed positive for CMV DNA, and ganciclovir instillation and valganciclovir administration were started. Because the corneal edema did not improve, penetrating keratoplasty was performed in February 2019. Case 2 was a 73-year-old man who had been treated with steroids and immunosuppressant instillation with Mooren's ulcer in the left eye from 2018. However, corneal edema, anterior chamber inflammation, and keratic precipitates appeared. PCR examination using an aqueous sample showed positive for CMV DNA at the first visit, and ganciclovir instillation was started. Although the anterior chamber inflammation improved, the thinning of the upper sclera gradually progressed. The preserved scleral keratoplasty and amniotic membrane transplantation were performed in March 2019.

Conclusion：Two cases of CMV showed corneal endotheliitis during treatment of Mooren's ulcer. It was suggested that CMV activation may occur during steroid and immunosuppressant administration.