Objective To evaluate the risk factors， clinical features， and treatment of recurrent herpes simplex keratitis after penetrating keratoplasty （PKP）. Methods This was a retrospective， interventional case series study. Three hundred twenty-nine patients （329 eyes） with herpes simplex keratitis who underwent penetrating keratoplasty at the Qingdao Eye Hospital between January 2000 and July 2012 were evaluated. All patients had failed to respond to topical and systemic antivirus drug treatment before penetrating keratoplasty was performed. The medical records of each patient were reviewed retrospectively. The clinical features， including recurrence time， position， and type， were summarized. Appropriate topical and systemic antivirus treatment was determined for all patients based on the clinical features. If there was treatment failure， conjunctival flap covering， amniotic membrane transplantation， or penetrating keratoplasty was performed. Results Thirty-three patients （10%） experienced recurrence after penetrating keratoplasty. The recurrent type was mainly epithelial （54%） and 63% of the recurrences were at the border between donor and recipient tissues. Recurrence risk factors included immune rejection， secondary glaucoma， cataract surgery， upper respiratory tract infection， and lesions involving the limbus. Ten cases of the epithelial condition took a turn for the better simply with drug treatment； the remaining stromal and endothelial conditions （including changes from epithelial conditions） needed surgery： 5 cases of conjunctival flap， 12 cases of amniotic membrance transplantation， and 6 cases with PKP. With an average of 24.6±5.4 months for follow-up after treatment， 46% of the eyes had clear grafts. Conclusion Immune rejection， secondary glaucoma， cataract surgery， upper respiratory tract infection， and lesions involving the limbus are major risk factors for the recurrence of herpes simplex keratitis after penetrating keratoplasty. Based on the clinical features of recurrence， appropriate precautions and treatment options can help to control recurrent infection.
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