Amniotic membrane transplantation combined with antiviral and steroid therapy for herpes necrotizing stromal keratitis

Purpose: To evaluate therapeutic effect of multilayer amniotic membrane transplantation (AMT) in conjunction with antiviral and corticosteroid therapy on herpes necrotizing stromal keratitis. Design: Retrospective interventional case series. Participants: Fifteen patients (15 eyes) with herpes necrotizing stromal keratitis, persistent corneal inflammation, and impending ulcer, despite topical and systemic antiviral treatment for over 2 weeks. Methods: Multilayer AMT was performed in the 15 eyes. Antiviral medications and appropriate corticosteroids were administered after surgery. Remodeling of amniotic membrane (AM) and growth of epithelial cells were detected by confocal microscopy. Main Outcome Measures: Visual acuity and corneal status (ulceration, edema, and opacification). Results: Follow-up ranged from 7 to 13 months (mean +/- standard deviation, 8.9 +/- 1.8). Visual acuity improved by >= 2 lines in 14 eyes. Central corneal ulcers healed completely at 2.0 +/- 0.6 weeks, and paracentral ulcers at 2.1 +/- 0.6 weeks (t = 0.314, P = 0.759). Corneal stromal thickness was restored in eyes with central ulcers at 2.4 +/- 1.2 weeks and in those with paracentral ulcers at 2.6 +/- 0.7 weeks (t = 0.425, P = 0.678). Superficial epithelial cells, together with small basal epithelial cells, gradually migrated to the surface of AM on postoperative weeks 1 to 3. There were corneal nebulae in 11 eyes, corneal maculae in 3 eyes, and a corneal leukoma in 1 eye at the end of follow-up. No recrudescence occurred in any eye. Conclusion: Multilayer AMT combined with antiviral and corticosteroid therapy appears effective in treating herpes necrotizing stromal keratitis. It provides patients with marked scars and visual impairment an opportunity for subsequent keratoplasty by arresting the inflammatory response and reducing the graft bed diameter.