Diagnosis And Management Of Herpetic Endotheliitis: Added Value Of Anterior Segment Oct

Herpetic endotheliitis is a stromal form of Herpes Simplex Keratitis, accounting for approximately 2% of primary herpetic manifestations and nearly half of recurrences. It may present as disciform, linear, or diffuse corneal edema and is typically characterized by stromal edema, Descemet membrane folds, and keratic precipitates. We report a case highlighting the diagnostic and therapeutic challenges of this condition and the role of Anterior Segment Optical Coherence Tomography in its evaluation.

Department of Ophthalmology, University Hospital.

We report the clinical presentation, imaging findings, management, and outcome of a 76-year-old woman with a history of systemic hypertension, asthma, and previous cataract surgery in the right eye. She presented with a painful red left eye and progressive visual impairment for more than one month. Initial examination revealed visual acuity limited to counting fingers at 1m, a central dendritic corneal ulcer, epithelial hypoesthesia, and a calme anterior chamber. Intraocular pressure was within normal limits. Oral antiviral therapy with Valaciclovir (1 g three times daily) was initiated, resulting in complete healing of the dendritic ulcer and improvement in visual acuity.Four weeks later, the patient presented with recurrence of symptoms. 

 Slit-lamp examination revealed localised corneal oedema with pigmented keratic precipitates, Descemet membrane folds, and anterior chamber inflammation without hypopyon. Fluorescein staining confirmed complete resolution of the epithelial lesion. A diagnosis of herpetic endotheliitis was strongly suspected. Antiviral therapy was intensified with intravenous Acyclovir. Anterior Segment Optical Coherence Tomography demonstrated hyperreflectivity of the endothelium and Descemet membrane, stromal thickening, and retro-Descemet precipitates associated with corneal oedema. Topical corticosteroids were cautiously introduced under antiviral coverage. 

Clinical evolution was favorable, with progressive resolution of corneal edema and improvement in visual acuity.Herpetic endotheliitis is a potentially sight-threatening condition requiring prompt recognition and appropriate management. A sequential therapeutic strategy combining intensive antiviral therapy followed by carefully monitored topical corticosteroids is essential to control inflammation while preventing viral reactivation. Anterior Segment Optical Coherence Tomography represents a valuable adjunctive tool for confirming endothelial involvement and guiding therapeutic decisions in herpetic keratitis