Adenovirus Type 8 Epithelial Keratitis: The Development, Accompanying Signs, and Sequelae

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Doris Summers
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1 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele 2 This hpter shows the evelopment of A8 kertitis in ptients of whom ll ut one (Cse 8) were expose to the virus uring nosoomil outrek of EKC. The infetion ws trnsmitte either iretly in the Clini or y infete ontts. Sine in linil prtie infetions with vrious enovirus serotypes nnot e istinguishe from eh other, A8 n serve s moel of sequene events ommon to ll of them. In the sene of ustive tretment, the ses presente in this hpter show the nturl ourse of the isese. Cortisone eye rops were not use exept for ouple of ys uring the ute stge in one ptient (Cse 8) euse of n initil ignosti error. In time perspetive, lking etter initors, the urtion of the kertitis t presenttion is relte to the onset of symptoms s reporte y the ptient, whih of ourse oes not tell when extly uring the ourse of the isese the ornel epithelium eme ffete. It might hve ourre erly, s shown in Cse 1 presenting out 30 h. fter the onset of symptoms. The morphologil omponents of enovirus epithelil kertitis re few (Chp. 1) n the ourse of the isese rther stereotype: first to pper re superfiil yst-like strutures; either onurrently with them, or shortly therefter, pper roune/norml ells, iniviul or groupe. During the next few ys, the numers of oth ten to inrese, n the roune/norml ells show propensity to hep-up; this phenomenon eventully results in lrger lesions terme enovirus epithelil infiltrtes. The yst-like strutures re first to ler. The numers of roune/norml ells, on the other hn, iminish only slowly, n in some ptients they persist for mny months or even yers fter the ute isese h susie. These re ptients who evelop sequel of enovirus epithelil kertitis terme suepithelil infiltrtes. Clinilly, this enomintion seems to pply to light-refleting fleks or opities, mil or ense, few or mny, present fter the integrity of the epithelil surfe hs een restore s juge y the sene of fluoresein stining. Pulishe histologil preprtions hve shown suepithelil umultions of inflmmtory ells, ut t wht point of time the suepithelil strom eomes involve seems unknown. In vivo, there is no rupt hnge, there is the sme ellulr omponent s efore, n the only initors of suepithelil involvement re strutures implying mge to the lmellr omposition of the superfiil strom the initil stges of whih re iffiult to etet. Sine the ells pper the sme uring the ourse of the isese, I hve hosen (Chp. 1) to use the purely esriptive term roune/norml ells irrespetive of their possile nture throughout the ook. Conerning the suepithelil infiltrtes, the terminology is even more hllenging. After hving ponere the question for while, I foun it prtil to use the term in orne with the linil pplition, i.e., lso in ses in whih no ler suepithelil stroml involvement hs een pture. The sustruture, the superfiil lotion, n the evelopment of suepithelil infiltrtes re shown in Cse 10 (f. lso Chp. 4). Dignosti errors ourring uring the perio of time elpsing etween symptom onset n (in the ontext) the ignosti enovirus epithelil infiltrtes highlight the importne of fmilirity with the pperne of the erly ornel mnifesttions: With the slit lmp, the orne ppers usty ut not lustreless; reful oservtion isloses the presene of light-refleting ots n, with fluoresein soium, mny surfe elevtions. If ttention is not pi, ptients with ompnying signs of nterior uveitis re esily ignose with primry uveitis, prtiulrly those with history of reurrent one (Cses 3 n 8). Very triky re lso nosoomil infetions superimpose on preexisting ornel epithelil iseses (Cses 9 n 10); efore n outrek is isovere, they ten to e erroneously ttriute to llergi retions to tretment. H.M. Tery, Aenovirus Epithelil Kertitis n Thygeson s Superfiil Puntte Kertitis, DOI / _2, Springer-Verlg Berlin Heielerg

14 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 1: EKC: An Ouptionl Hzr Cse Report A 40-yer-ol womn presente with irrittion, foreign oy senstion, tering, n

2 14 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 1: EKC: An Ouptionl Hzr Cse Report A 40-yer-ol womn presente with irrittion, foreign oy senstion, tering, n reness of the right eye, ll strting out 30 h. efore exmintion. The lis were slightly swollen, the eye moertely injete, the onjuntiv showe folliulr hyperplsi n, with fluoresein soium, myris of green ots; with the slit lmp, the ornel epithelium ppere slightly hzy. The left eye ws white. Aenovirus infetion ws suspete. The fellow eye eme ffete 3 ys lter ut less severely. The photogrphs of the right orne were tken t presenttion n 5, 12, n 20 ys, n 2 months fter the onset of symptoms. (out) 30 h Fig. 2.1 ( ) Aout 30 h fter the onset of symptoms, the ornel epithelium shows isrete roune yst-like strutures (lk rrowhes). The smller strutures (white rrowhes) might represent roune/norml ells (f. Fig. 2.2, opposite pge) Comment It is unommon to see ptient presenting tht erly fter the onset of symptoms. This ptient ws stff memer whose symptoms h strte uring just isovere outrek of nosoomil infetion.

3 EKC: An Ouptionl Hzr (Cse 1, ont.) 15 EKC: An Ouptionl Hzr (Cse 1, ont.) 5 ys e Fig. 2.2 ( e) Five ys fter symptom onset. In ( ) re visile roune/norml ells (white rrowhes) n mny roune yst-like strutures (lk rrowhes) whih (e) re protruing (rk; rrowhes) in the ter film stine green with fluoresein. (Cf. Figs. 2.6 n 2.7)

16 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele EKC: An Ouptionl Hzr (Cse 1, ont.) 12 ys Fig. 2.3 (, ) Twelve ys fter symptom onset, the epithelium is hevily isture.

(Apte from [4]) 20 ys Fig. 2.4 ( ) Twenty ys fter symptom onset, the epithelium shows () roune/norml ells (rrowhe); they re (, ) light refleting (rrowhes).

4 16 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele EKC: An Ouptionl Hzr (Cse 1, ont.) 12 ys Fig. 2.3 (, ) Twelve ys fter symptom onset, the epithelium is hevily isture. It shows mny roune/norml ells (white rrowhes), iniviul or groupe, n istint epithelil ysts (lk rrowhes). In ples, the ells seem mixe with ell eris (, rrows). (Apte from [4]) 20 ys Fig. 2.4 ( ) Twenty ys fter symptom onset, the epithelium shows () roune/norml ells (rrowhe); they re (, ) light refleting (rrowhes). () With fluoresein re visile rillintly green ots, iniviul (short rrows) or groupe (long rrow), n surfe elevtions (rk; owe rrow)

5 EKC: An Ouptionl Hzr (Cse 1, ont.) 17 EKC: An Ouptionl Hzr (Cse 1, ont.) 2 months Fig. 2.5 (, ) Two months fter symptom onset () lesion (rrow) tht ontins roune/norml ells (rrowhe) is visile; suh ells (rrowhe) re lso present outsie it. () Two lesions stining green with fluoresein (lue filter) Comment Sometimes, new surfe isruptions our long fter the surfe hs een restore. Cf. Figs n Aenum This ptient evelope ense suepithelil opities/infiltrtes tht only grully fe wy.

18 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 2: A Sequel of Frienly Visit Cse Report A 77-yer-ol mn ws referre to the Eye Clini y generl prtitioner euse

6 18 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 2: A Sequel of Frienly Visit Cse Report A 77-yer-ol mn ws referre to the Eye Clini y generl prtitioner euse of left-sie onjuntivitis of 4 ys urtion. The left eye ws injete, the onjuntiv swollen, n the orne showe mny ust-like epithelil ots n fols of the Desemet s memrne. The right eye ws white. Aenovirus ws suspete. The following y, the ptient presente gin euse of worsening of symptoms. The right eye ws slightly injete n showe mny folliles in the lower fornix, n the symptoms in the left eye were more severe. The soure of the infetion ws tre to ontt with lose frien who h ontrte nosoomil infetion. Three months fter onset, the right orne showe two isrete suepithelil opities/infiltrtes n the left orne severl ense ones. 7.5 months fter onset, the right orne ws ler n the periphery of left one showe few isrete suepithelil opities. The photogrphs of the left orne were tken 5 n 19 ys, n 3 n 7.5 months fter the onset of symptoms. 5 ys Fig. 2.6 (, ) Five ys fter symptom onset. Survey. () Without stining, the epithelium shows mny fine ots spre over the surfe, iniviul (rrowhe) or groupe (rrow). (Compose photogrph.) () With fluoresein re visile mny roune rk (rrowhe) n some rillintly green (rrow) ots. For etils see Fig. 2.7 (opposite pge)

A Sequel of Frienly Visit (Cse 2, ont.) 19 A Sequel of Frienly Visit (Cse 2, ont.) 5 ys e f Fig. 2.7 ( f) The orne shown in Fig. 2.6.

7 A Sequel of Frienly Visit (Cse 2, ont.) 19 A Sequel of Frienly Visit (Cse 2, ont.) 5 ys e f Fig. 2.7 ( f) The orne shown in Fig Visile re ( ) roune/norml ells, iniviul (white rrowhes) or groupe (rrows), () yst-like hnges (lk rrowhes), n ( n ) epithelil ysts (lk rrowhes). (e, f) With fluoresein re visile smll protrusions (rk; rrowhes) in the green stine ter film n few green ots (rrow)

20 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele A Sequel of Frienly Visit (Cse 2, ont.) 19 ys Fig. 2.8 ( ) Nineteen ys fter symptom onset, the orne shows mny roune/norml ells (rrowhes), in () hepe-up in istint epithelil infiltrte (rrow).

8 20 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele A Sequel of Frienly Visit (Cse 2, ont.) 19 ys Fig. 2.8 ( ) Nineteen ys fter symptom onset, the orne shows mny roune/norml ells (rrowhes), in () hepe-up in istint epithelil infiltrte (rrow). (; pte from [4])

9 A Sequel of Frienly Visit (Cse 2, ont.) 21 A Sequel of Frienly Visit (Cse 2, ont.) 3 months 7.5 months Fig. 2.9 ( ) Three months fter symptom onset, the orne shows suepithelil opities/infiltrtes ontining roune/ norml ells, iniviul (rrowhes) or groupe (lk rrows); () shows their light-refleting property n surfe elevtion (rk; owe rrow). (The lk rrows n the rrowhes re ple in orresponing lotions.) Inset: roune/ norml ells (rrowhe) present 7.5 months fter onset

22 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 3: Anterior Uveitis n Nosoomil Infetion Cse Report A 74-yer-ol womn trete with ortisone eye rops for

10 22 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 3: Anterior Uveitis n Nosoomil Infetion Cse Report A 74-yer-ol womn trete with ortisone eye rops for right-sie nterior uveitis. Nine ys fter the lst visit, she presente gin euse of ugmenting reness n irrittion in the fellow eye. Both eyes were slightly injete n the ornee showe isrete ust-like epithelil ots. Four ys lter, when the lis were swollen n the ornee itionlly showe fols of the Desemet s memrne, enovirus ws suspete. Six weeks fter symptom onset, the eyes were white n the ornee ler. She never evelope suepithelil opities/infiltrtes. The photogrphs of the left orne were tken 9 n 15 ys fter the onset of symptoms. 9 ys 15 ys Fig ( ) Nine ys fter symptom onset, the orne shows () roune/norml ells (rrowhes) n () roune protrusions (rk; rrowhes) n green ots (rrow) in the ter film stine green with fluoresein. () Roune/norml ells (rrowhes), in ples groupe (rrow) re still present 15 ys fter onset. () shows, for omprison, inflmmtory ells (rrowhe) tthe to the enothelium uring mil nterior uveitis present 15 ys fter the onset of symptoms reltle to A8 infetion

The photogrphs of the left orne were tken 17 ys fter symptom onset. 17 ys Fig. 2.

11 Cse 4: A Cse of Cring Wife 23 Cse 4: A Cse of Cring Wife Cse Report This 87-yer-ol womn, who h ministere eye rops to her husn with nosoomil infetion, presente with ilterl kertoonjuntivitis 4 ys fter symptom onset. She evelope mny suepithelil opities/infiltrtes still present 2 yers lter. The photogrphs of the left orne were tken 17 ys fter symptom onset. 17 ys Fig ( ) A hevy isturne of the epithelil rhiteture highlighte with fluoresein. (, ) show surfe elevtions (rk; owe rrow n rrowhes) n rillintly green ots (stright rrows). In (, ) re visile green ots (rrows) n roune/norml ells (rrowhes)

24 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 5: Nosoomil Infetion After Suture Removl Cse Report A 85-yer-ol womn presente with irrittion n foreign oy

12 24 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 5: Nosoomil Infetion After Suture Removl Cse Report A 85-yer-ol womn presente with irrittion n foreign oy senstion in her left eye. An ol ornel suture fter previous trt opertion ws remove. Sixteen ys lter she presente gin, this time euse of irrittion n reness in oth eyes tht h strte week erlier (9 ys fter her first visit). The lis were swollen, the onjuntive injete n swollen, n the ornee showe fine epithelil ots n fols of the Desemet s memrne. Nosoomil enovirus infetion ws suspete. She evelope isrete suepithelil opities/infiltrtes in oth ornee; only few very fint ones with no visul onsequenes were present 7 months fter symptom onset. The photogrphs of the left orne were tken 2 weeks, 4 weeks, n 7 months fter the onset of symptoms. 2 weeks Fig (, ) Survey of ornel epithelil hnges pture 2 weeks fter the onset of symptoms. The epithelium shows mny roune/norml ells (white rrowhes), in ples groupe (rrow), n mny smll ysts (lk rrowhes) spre over the surfe (ompose photogrphs). For etils see Fig (opposite pge)

Nosoomil Infetion After Suture Removl (Cse 5, ont.) 25 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 2 weeks e f Fig. 2.13 ( f) Two weeks fter symptom onset.

13 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 25 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 2 weeks e f Fig ( f) Two weeks fter symptom onset. The epithelium is hevily isture. It shows mny roune/norml ells (white rrowhes) n smll ysts (lk rrowhes); of these, mny ontin roune ell. (This phenomenon is unspeifi)

26 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion After Suture Removl (Cse 5, ont.) 4 weeks Fig. 2.14 ( ) Four weeks fter symptom onset, the epithelium shows ( n ) mny roune/norml ells, iniviul (white rrowhes) or groupe (rrows) n yst (lk rrowhe).

14 26 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion After Suture Removl (Cse 5, ont.) 4 weeks Fig ( ) Four weeks fter symptom onset, the epithelium shows ( n ) mny roune/norml ells, iniviul (white rrowhes) or groupe (rrows) n yst (lk rrowhe). () In the ter film stine green with fluoresein re visile surfe elevtions (rk; owe rrow) n rillintly green ots (short rrow)

Nosoomil Infetion After Suture Removl (Cse 5, ont.) 27 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 4 weeks Fig. 2.15 (, ) Different res of the sme orne s in Fig.

16 (, ) Seven months fter epithelil kertitis the orne shows () fint suepithelil opities /infiltrtes ontining few light-refleting

15 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 27 Nosoomil Infetion After Suture Removl (Cse 5, ont.) 4 weeks Fig (, ) Different res of the sme orne s in Fig showing roune/norml ells (rrowhes); in the group inite y rrow, the ells seem mixe with ell eris 7 months Fig (, ) Seven months fter epithelil kertitis the orne shows () fint suepithelil opities /infiltrtes ontining few light-refleting roune/norml ells, iniviul (rrowhes) or groupe (rrows). (The mrkers re ple in orresponing lotions)

28 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 6: Nosoomil Infetion After Applntion Tonometry Cse Report Six ys fter visit to the Eye Clini, 62-yer-ol womn

16 28 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 6: Nosoomil Infetion After Applntion Tonometry Cse Report Six ys fter visit to the Eye Clini, 62-yer-ol womn with gluom woke up with reness n irrittion in the left eye. The eye ws slightly injete n the lower fornix showe folliulr hyperplsi; the orne ppere norml. A week lter, oth eyes were injete n within further 5 ys evelope mny ornel epithelil infiltrtes. Sixteen months fter onset, the left orne showe mny ense suepithelil opities/infiltrtes. The photogrphs of the left orne were tken 12 ys n 7 weeks fter the onset of symptoms. 12 ys 7 weeks e f Fig (, ) Twelve ys fter symptom onset re visile roune/norml ells, iniviul (rrowhes) or hepe-up n pprently mixe with ell eris (rrows). (, ) Suepithelil opities/infiltrtes 7 weeks fter symptom onset (rrows). (e) Roune/norml ells, iniviul (rrowhe) or groupe (rrow) re (f) light-refleting (rrowhe). (Cf. Figs. 2.4, 2.21, 2.26, 2.27)

Cse 7: A Womn Infete y Cring Reltive 29 Cse 7: A Womn Infete y Cring Reltive Cse Report To this 77-yer-ol womn, the virus ws trnsmitte y reltive (herself mother of ptient with nosoomil infetion) who

17 Cse 7: A Womn Infete y Cring Reltive 29 Cse 7: A Womn Infete y Cring Reltive Cse Report To this 77-yer-ol womn, the virus ws trnsmitte y reltive (herself mother of ptient with nosoomil infetion) who ws nursing her. She suffere severe ilterl kertoonjuntivitis strting in the left eye n susequently evelope mny suepithelil opities/infiltrtes interfering with vision in oth eyes. The photogrphs of the left orne were tken 4 weeks n 17 months fter the onset of symptoms. 4 weeks 17 months Fig () Four weeks fter symptom onset, the orne shows roune/norml ells, iniviul (rrowhes) or groupe (rrows). ( ) Suepithelil opities/infiltrtes ontining roune/norml ells (rrowhes) 17 months fter onset. In () re visile surfe elevtions (rk, rrow) present in the sme re s in (); the surfe ppers intt. (The rrowhes re ple in orresponing lotions)

30 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 8: A Potentil Soure of Nosoomil Outrek Cse Report In 76-yer-ol womn with history of reurrent ilterl nterior

18 30 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 8: A Potentil Soure of Nosoomil Outrek Cse Report In 76-yer-ol womn with history of reurrent ilterl nterior uveitis n ornel mrginl infiltrtions, n inipient enovirus infetion ws onfuse with n inipient reurrene of nterior uveitis. She stoppe using steroi eye rops fter few ys euse of symptom worsening. At presenttion, 10 ys lter, oth eyes were injete, n the ornee showe ust-like epithelil kertitis; the right orne itionlly showe fols of the Desemet s memrne. Aenovirus ws suspete; lortory tests revele A8. The photogrphs of the left orne were tken 11 n 20 ys fter the onset of symptoms. 11 ys e f

19 A Potentil Soure of Nosoomil Outrek (Cse 8, ont.) 31 A Potentil Soure of Nosoomil Outrek (Cse 8, ont.) 20 ys Fig (, ) Twenty ys fter symptom onset, the orne still shows () mny roune/norml ells (rrowhes) n (), with fluoresein, surfe elevtions (owe rrow) n few green stine ots (short rrow) Aenum The ptient h quire the infetion in Centrl Europe. With n outrek of nosoomil A8 infetion fresh in min, the wreness of the nger ws still high n there ws only one seonry se. The ptient ws followe for further 1.5 yers euse of reurrent nterior uveitis. She evelope only one very fint peripherl suepithelil opity. Dry eye ws ignose 4 months fter the infetion. Fig ( f) (opposite pge) Eleven ys fter symptom onset. The epithelium shows ( ) mny roune/norml ells, iniviul (white rrowhes) or groupe (rrows) n yst (lk rrowhe). (e, f) show the sme re s (). (e) Dmge surfe ells stin re with rose engl. (f) Between re stine ells re visile fluoresein stine ots (green, rrowhe). (The mrkers re ple in orresponing lotions)

32 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 9: Nosoomil Infetion in Contt Lens Werer Cse Report A 28-yer-ol ontt lens werer presente in the Emergeny

20 32 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 9: Nosoomil Infetion in Contt Lens Werer Cse Report A 28-yer-ol ontt lens werer presente in the Emergeny Deprtment euse of irrittion n reness in oth eyes. At tht osion, n 4 ys lter, the ornel epithelium showe unspeifi superfiil hnges suggestive of ontt lens overwer. Six ys fter the seon visit he presente gin euse of symptom worsening in oth eyes. The ornel epithelium showe only fine epitheliopthy ut there were new finings: li swelling, folliulr hyperplsi, onjuntivl injetion, ll severe, n pinful swelling of preuriulr lymph noe. These finings were strongly suggestive of enovirus infetion. A week lter, the symptoms were less severe ut oth ornee showe mny epithelil infiltrtes. The photogrphs of the left orne were tken t tht osion, out 10 ys fter the onset of symptoms reltle to enovirus infetion. 10 ys Fig ( ) This epithelil infiltrte (rrows), pture out 10 ys fter symptom onset () is light-refleting, () ontins roune/norml ells (rrowhe), () shows irumsript green fluoresein stining, n () re rose engl stining of mge superfiil ells/ell eris. In () re lso visile roune/norml ells (white rrowhe) n few jent ysts or yst-like strutures (lk rrowhe). (The rrows re ple in orresponing lotions)

Nosoomil Infetion in Contt Lens Werer (Cse 9, ont.) 33 Nosoomil Infetion in Contt Lens Werer (Cse 9, ont.) 10 ys Fig. 2.

21 Nosoomil Infetion in Contt Lens Werer (Cse 9, ont.) 33 Nosoomil Infetion in Contt Lens Werer (Cse 9, ont.) 10 ys Fig ( ) Different res of the sme orne s in Fig show ( ) roune/norml ells (white rrowhes) n ysts or yst-like strutures (lk rrowhes). In () is itionlly visile prt of n epithelil infiltrte (rrow), n in (), with fluoresein, mny smll surfe elevtions (rk; rrowhe) n few rillintly green ots (rrows)

34 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 10: Nosoomil Infetion in Cornel Erosion Cse Report A 53-yer-ol womn ws peke in her left eye y her pet ir.

22 34 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Cse 10: Nosoomil Infetion in Cornel Erosion Cse Report A 53-yer-ol womn ws peke in her left eye y her pet ir. A len epithelil erosion ws trete with ntiioti ointment. Seventeen ys lter, she ws referre y prtitioner k to the Eye Clini euse symptom worsening. In the left eye, the lis were swollen, the onjuntiv injete n swollen, n the orne showe lrge erosion; the remining epithelium ws swollen n there were fols of the Desemet s memrne. In ition, she h symptoms lso in the fellow eye, for 4 ys; tht eye ws moertely injete n the ornel epithelium ppere usty. Nosoomil A8 infetion ws suspete. After further 2 ys, the right orne showe epithelil infiltrtes. The erosion in the left eye hele within further 3 ys, ut the orne strte to show mny epithelil infiltrtes. Dense suepithelil opities/infiltrtes interfering with vision evelope in oth ornee; they were still present yer fter the infetion. The photogrphs of the right (not trumtize) orne were tken 6 n 7 ys; 4, 6, n 9 weeks; 3, 5, n 8 months; n 1 yer fter the onset of symptoms. 6 ys e Fig ( ) Six ys fter symptom onset, the epithelium shows mny roune/norml ells (white rrowhes), iniviul or hepe-up (, rrow) n yst-like strutures (lk rrowhes). (e) With fluoresein, the surfe of n infiltrte (long rrow) shows rillintly green ots (short rrow); there is no iffusion into the surrounings

Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 35 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 7 ys Fig. 2.

23 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 35 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 7 ys Fig () Seven ys fter symptom onset re visile roune/norml ells, iniviul (rrowhe) or groupe (rrow). () Survey showing irumsript green stining (short rrow) of epithelil infiltrtes (long rrow) n jent surfe elevtions (rk; owe rrow). The re in frme is shown t higher mgnifition in () n (). () The lesion (rrow) ontins umulte roune/norml ells (white rrowhe) pprently mixe with ell eris. Roune/norml ells, iniviul (white rrowhe) or groupe (lk rrows) n yst-like strutures (lk rrowhes) re visile in the surrounings. () Some groups of roune/norml ells (lk rrows) n some yst-like strutures (lk rrowhes) stin rillintly green, others re protruing (rk) in the green stine ter film. (In n, the rrows n the lk rrowhes re ple in orresponing lotions)

36 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 4 weeks Strom Surfe e Fig. 2.25 ( e) Four weeks fter symptom onset, the orne shows suepithelil opities/infiltrtes (rrows).

24 36 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 4 weeks Strom Surfe e Fig ( e) Four weeks fter symptom onset, the orne shows suepithelil opities/infiltrtes (rrows). () Survey. () The infiltrte (rrow) onsists of more or less light-refleting res, hs inistint eges, () is superfiilly lote elow (, ) n pprently intt surfe, n (e) ontins roune/norml ells (rrowhe). (The rrows in n re ple in orresponing lotions)

Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 37 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 6 weeks Fig. 2.26 ( ) Six weeks fter symptom onset.

25 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 37 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 6 weeks Fig ( ) Six weeks fter symptom onset. () A suepithelil opity/infiltrte with inistint eges. () With fluoresein, the overlying epithelium ppers intt. () The light-refleting res show roune/norml ells (rrowhe); the ells seem mixe with light-refleting mteril suggestive of ell eris. (The mrkers re ple in orresponing lotions.) () A ifferent re showing the presene of groupe roune/norml ells (rrowhe)

38 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 9 weeks e f Fig. 2.27 ( f) Nine weeks fter symptom onset, the orne shows ( n ) mny suepithelil opities/infiltrtes (rrows) lote elow () n pprently intt surfe.

26 38 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 9 weeks e f Fig ( f) Nine weeks fter symptom onset, the orne shows ( n ) mny suepithelil opities/infiltrtes (rrows) lote elow () n pprently intt surfe. (, ) show t higher mgnifition the res inite y frmes in (); roune/norml ells re visile in oth (rrowhes). (e, f) show t higher mgnifition the re inite y frme in (). In (f) re visile groups of roune/norml ells (rrowhes), in ples possily mixe with ell eris (rrow), n in (e) their light-refleting property. (The mrkers re ple in orresponing lotions)

Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 39 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 3 months Strom Surfe e Fig. 2.28 ( e) Three months fter symptom onset.

27 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 39 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 3 months Strom Surfe e Fig ( e) Three months fter symptom onset. (, ) The suepithelil opities/infiltrtes (rrows) ontin () lightrefleting ots (rrowhe). () shows their lotion elow n pprently intt surfe, () the presene of roune/norml ells (rrowhe) in the re inite y frme in (), n (e) groups of roune/norml ells (rrows). (The rrows in n re ple in orresponing lotions)

40 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 5 months Fig. 2.29 ( ) Five months fter symptom onset, the orne shows (, ) suepithelil opities/infiltrtes (rrows).

28 40 2 Aenovirus Type 8 Epithelil Kertitis: The Development, Aompnying Signs, n Sequele Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 5 months Fig ( ) Five months fter symptom onset, the orne shows (, ) suepithelil opities/infiltrtes (rrows). In (, ) re visile groups (rrows) of roune/norml ells. (The rrows in n re ple in orresponing lotions)

Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 41 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 8 months 1 yer Fig. 2.

29 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 41 Nosoomil Infetion in Cornel Erosion (Cse 10, ont.) 8 months 1 yer Fig ( ) The pperne of suepithelil opities/infiltrtes (long rrows) (,, n ) 8 months n () 1 yer fter the onset of symptoms. The infiltrte inite y short rrow in () is shown t higher mgnifition in (, ). () Fluoresein visulizes smll surfe isruption (rrow). () The infiltrte ontins roune/norml ells (rrowhe). (The short rrows in,, n re ple in orresponing lotions)

The Dynamics of Varicella-Zoster Virus Epithelial Keratitis in Herpes Zoster Ophthalmicus

The Dynamics of Varicella-Zoster Virus Epithelial Keratitis in Herpes Zoster Ophthalmicus Chpter 2 The Dynmics of Vricell-Zoster Virus Epithelil Kertitis in Herpes Zoster Ophthlmicus The morphology of n individul VZV lesion reflects sequence of events triggered y the virus impct on cornel epithelil