- Brief report
- Open Access
Keratoconus-like tomographic changes in a case of recurrent interstitial keratitis
© The Author(s). 2018
- Received: 2 November 2017
- Accepted: 13 February 2018
- Published: 7 March 2018
The purpose of this report was to describe a single case of recurrent interstitial keratitis in a young patient leading to keratoconus-like corneal changes.
Over the 2 years follow-up, the patient developed clinical signs of keratoconus with Vogt’s striae, Fleischer Ring and paracentral stromal thinning in the affected eye only. The tomographic measurements revealed a rapid reduction of corneal thickness from 581 to 303 μm and an irregular steepening of the pathological cornea. True net corneal power increased from 42.8 to 48.8 dioptres (D) and maximal power of the anterior surface from 44.9 to 66.9 D. Best-corrected visual acuity (BCVA) decreased from 20/20 to 20/200. A penetrating excimer laser keratoplasty was performed to restore vision and corneal stability.
Keratoconus-like changes can occur in young patients with recurrent interstitial keratitis and request corneal transplantation.
- Interstitial keratitis
Keratoconus is a degenerative disorder of the cornea associated with corneal thinning and ectasia that leads to refractive errors and impaired vision. It is mostly bilateral, typically affects adolescents or young adults and may progress until the third or fourth decade of life, when it usually arrests .
The pathophysiology of keratoconus is complex and still remains unclear.
Recent studies revealed the probable influence of inflammatory mechanisms in the pathogenesis of keratoconus and emphasises the importance of controlling inflammation to prevent progression of the disease [2–4].
Infectious keratitis can cause topographic changes resulting in visual impairment. This phenomenon was recently investigated, and tomographic measurements of post-infected corneas revealed different patterns of corneal aberrations including protrusion keratoconus-like patterns [5, 6].
In support of these considerations, we report the case of a young patient with clinical manifestations of corneal inflammation, who developed strictly unilateral keratoconus-like changes in the affected eye.
A 27-year-old Caucasian man was referred to our center with complaints of persistent blurred vision on the left eye. He was treated with corticoid eye drops and systemic acyclovir tablets for the past 2 months on the suspicion of herpetic keratitis. No other ophthalmological pathology or systemic disease was documented.
Based on the clinical diagnosis of non-necrotising stromal keratitis of presumed herpetic origin, we treated the patient with corticoid eye drops, ganciclovir eye gel and acyclovir tablets. During the 2-year follow-up of the patient, relapses occurred with reduction of the therapy, which required regular increases of the frequency of topical therapy application or temporary use of systemic steroid.
Evolution of the left eye
Pachymetry at the thinnest point (μm)
Power of the anterior surface (dpt)
Power of the posterior surface (dpt)
True net power (dpt)
An excimer laser supported penetrating corneal transplantation was carried out at this point on the left eye.
Originally, keratoconus was presented as a non-inflammatory disorder affecting primarily young men, usually bilateral and leading to visual impairment. Although the pathogenesis of keratoconus remains poorly understood, multiple studies revealed the importance of inflammation in the progression of the disease and a recent consensus was to consider keratoconus an inflammatory disease [3, 4]. Accordingly, novel therapeutic approaches aiming to prevent keratoconus progression through reduction of inflammation were evaluated. The topical application of immune-modulator cyclosporine A demonstrated encouraging results in a small amount of keratoconus patients .
Eye rubbing, atopy or contact lens wear were also revealed as risk factors in clinical and experimental studies, suggesting the role of environmental aspects [7–9]. As eye rubbing showed to be associated with increased levels of proinflammatory mediators in tears, its influence on keratoconus may be related to pro-inflammatory effect . Keratoconus has also been associated with metabolic disorders of the urea cycle  and thyroid gland dysfunction . Multiple studies support the influence of genetic components in the pathogenesis of the disease [9, 12].
In recent studies, the effect of infectious keratitis on corneal topography was investigated [5, 6]. The topographic changes due to infectious keratitis seem to depend on the location of the inflammation and the healing response of the host. Although asymmetric patterns appeared to be the most common, protrusion patterns were also revealed . The pathogenesis of these changes has not been elucidated yet, but the first patterns may be associated to stiffening of the inflamed cornea due to a predominance of scarring process, whereas the second, keratoconus-like patterns would arise through stromal melting. Optical aberrations caused by topographic changes of the cornea were revealed, as well as corneal opacification, to be responsible for visual impairment following infectious keratitis .
Our patient had no systemic disease or familial history of keratoconus. He developed rapid keratoconus-like corneal changes on the eye with recurrent inflammatory manifestations but no clinical signs of keratoconus in the other eye. This clinical case may support the essential role of inflammation in the development and progression of keratoconus-like ecstasies. Although the cause remains unclear, the rapidity of the progression of keratoconus in this case could be related to the age of the patient, which correlates with the usual onset of the disease.
This case demonstrates that keratitis may lead to keratoconus-like corneal changes and supports the hypothesis of a causative link between recurrent inflammatory process and the development of keratoconus. It provides additional arguments towards the use of stronger anti-inflammatory medications or immunosuppressive drugs such as cyclosporine in similar cases to prevent corneal ectasia and corneal transplantation.
No funding sources.
MSH collected the data and wrote the main manuscript text. All authors read and approved the final manuscript.
Consent for publication
An informed consent for publication was obtained from the patient.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.
- Rabinowitz YS (1998) Keratoconus. Surv Ophthalmol 42:297–319View ArticlePubMedGoogle Scholar
- Shetty R, Ghosh A, Lim RR, Subramani M, Mihir K, Reshma AR, Ranganath A, Nagaraj S, Nuijts RM, Beuerman R, Shetty R, Das D, Chaurasia SS, Sinha-Roy A, Ghosh A (2015) Elevated expression of matrix metalloproteinase-9 and inflammatory cytokines in keratoconus patients is inhibited by cyclosporine A. Invest Ophthalmol Vis Sci 56:738–750View ArticlePubMedGoogle Scholar
- Galvis V, Sherwin T, Tello A, Merayo J, Barrera R, Acera A (2015) Keratoconus: an inflammatory disorder? Eye (Lond) 29:843–859View ArticleGoogle Scholar
- Wisse RP, Kuiper JJ, Gans R, Imhof S, Radstake TR, Van der Lelij A (2015) Cytokine expression in keratoconus and its corneal microenvironment: a systematic review. Ocul Surf 13:272–283View ArticlePubMedGoogle Scholar
- Shimizu E, Yamaguchi T et al (2017) Corneal higher-order aberration in infection keratitis. Am J Ophthalmol 175:148–158View ArticlePubMedGoogle Scholar
- Kashizuka E, Yamaguchi T et al (2016) Corneal higher-order aberrations in herpes simplex keratitis. Cornea Epub ahead of printsGoogle Scholar
- Ioannidis AS, Speedwell L, Nischal KK (2005) Unilateral keratoconus in a child with chronic and persistent eye rubbing. Am J Ophthalmol 139:356–357View ArticlePubMedGoogle Scholar
- Galvis V, Tello A, Carreño NI, Berrospi RD, Niño CA (2017) Risk factors for keratoconus: atopy and eye rubbing. Cornea 36:1View ArticleGoogle Scholar
- Gordon-Shaag A, Millodot M, Shneor E, Yutao L (2015) The genetic and environmental factors for keratoconus. Biomed Res Int. https://doi.org/10.1155/2015/795738
- Stachon T, Kolev K, Flaskó Z, Seitz B, Langenbucher A, Szentmáry N (2017) Arginase activity, urea, and hydroxyproline concentration are reduced in keratoconus keratocytes. Graefes Arch Clin Exp Ophthalmol 255:91–97View ArticlePubMedGoogle Scholar
- Thanos S, Oellers P, Zu Hörste M, Prokosch V, Schlatt S, Seitz B, Gatzioufas Z (2016) Role of thyroxine in the development of keratoconus. Cornea 35:1338–1346View ArticlePubMedGoogle Scholar
- Nowak DM, Gajecka M (2011) The genetics of keratoconus. Middle East Afr J Ophthalmol 18(1):2.View ArticlePubMedPubMed CentralGoogle Scholar