Chronic Corneal Edema And Stromal Haze With Presumed Herpetic Endotheliitis.

To describe the clinical findings, diagnostic evaluation, and stepwise therapeutic management of a patient presenting with chronic corneal edema and stromal haze with moderate visual impairment and normal intraocular pressure (IOP), raising suspicion of previous herpetic endotheliitis. 

The patient was evaluated and managed in our specialized ophthalmology clinic equipped with slit-lamp biomicroscopy, anterior segment OCT, pachymetry, and specular microscopy for detailed corneal assessment and endothelial evaluation.

A patient presented with a one-year history of progressive blurred vision. BCVA was 5/10 in the right eye and 4/10 in the left; IOP was 15 mmHg. Slit-lamp examination showed corneal edema and stromal haze without active epithelial lesions. Specular microscopy could not be performed. Central corneal thickness measurement confirmed the edema. Given the symptoms and clinical suspicion of herpetic endothelial involvement, treatment was initiated with topical ganciclovir gel, hypertonic sodium chloride gel, and topical corticosteroid eye drops. The patient was re-evaluated after 15 days, with partial clinical improvement. Systemic antiviral therapy with oral valacyclovir was added. A follow-up two weeks later documented further improvement.

At the first follow-up visit, mild improvement in corneal transparency and subjective visual acuity was observed, 6/10 in both eyes, while intraocular pressure remained stable. Stromal haze was reduced but not completely resolved. Following the addition of systemic antiviral therapy, progressive reduction of corneal edema and further improvement in visual acuity were noted. We were also able to perform specular microscopy. The positive response to combined topical and systemic antiviral therapy supported the diagnosis of presumed herpetic endotheliitis. 

Chronic corneal edema with stromal haze and normal intraocular pressure should prompt consideration of herpetic endotheliitis, even in the absence of documented acute infection. Diagnostic limitations, such as inability to initially assess endothelial cell density, may complicate evaluation. Combined topical antiviral and corticosteroid therapy, supplemented with systemic antiviral treatment when indicated, may improve corneal clarity and stabilize visual function. Early diagnosis and targeted management are crucial to prevent irreversible endothelial cell loss and long-term visual impairment.