One Disease, Three Outcomes: Individualized Management In Herpetic Endotheliitis

To emphasize the heterogeneous clinical course of herpetic endotheliitis and to demonstrate that therapeutic management must be individualized according to the stage of endothelial damage. Through three clinical scenarios, we aimed to illustrate the spectrum of evolution ranging from reversible inflammatory endothelial dysfunction responsive to antiviral therapy, to irreversible endothelial failure requiring Descemet Membrane Endothelial Keratoplasty (DMEK), and finally to postoperative viral recurrence occurring on an initially successful graft.

Department of Ophthalmology, Tertiary Referral Center for Corneal Diseases and Endothelial Keratoplasty, Hospital Cheikh Zaïd, Rabat, Morocco, a national referral center managing complex viral corneal pathologies and advanced endothelial surgical procedures.

We report a descriptive series of three patients aged 50, 41, and 63 years followed for recurrent herpetic endotheliitis. Baseline evaluation included best-corrected visual acuity (BCVA), intraocular pressure measurement, slit-lamp biomicroscopy documenting corneal edema and inflammatory signs, and anterior segment OCT assessing endothelial decompensation. All patients received systemic antiviral therapy combined with adjusted topical corticosteroids. In cases of persistent stromal edema, reduced vision, and OCT-confirmed irreversible endothelial failure despite optimized medical treatment, DMEK was performed. Long-term antiviral prophylaxis and close postoperative surveillance were systematically implemented.

The first patient presented acute inflammatory endotheliitis with stromal edema and a Khodadoust line; medical therapy alone resulted in complete resolution and BCVA improvement from 4/10 to 8/10. The second patient developed progressive central corneal edema unresponsive to antivirals, evolving toward irreversible endothelial failure; DMEK achieved rapid corneal clarity and significant visual recovery. The third patient, pseudophakic, presented diffuse edema and ocular hypertension requiring DMEK; although initial graft attachment and transparency were satisfactory, postoperative herpetic recurrence led to renewed corneal edema, necessitating intensified antiviral treatment.

Herpetic endotheliitis exhibits unpredictable and stage-dependent progression. Management must be tailored to the severity of endothelial involvement. While early inflammatory dysfunction may be reversible under medical therapy, advanced decompensation requires endothelial keratoplasty. However, surgical replacement of the endothelium does not eliminate viral latency, and recurrence on a clear graft remains a significant risk factor for long-term graft survival, highlighting the necessity of prolonged antiviral prophylaxis and strict follow-up.