HERPES SIMPLEX VIRUS ENDOTHELIITIS: A COMPREHENSIVE REVIEW OF PATHOPHYSIOLOGY, DIAGNOSIS, AND CONTEMPORARY MANAGEMENT

Description

Abstract Herpes simplex virus (HSV) endotheliitis is an immune-mediated inflammatory disorder of the corneal endothelium that occurs in the context of recurrent ocular HSV infection. It is characterised by corneal oedema, keratic precipitates, and a mild-to-moderate anterior chamber reaction, and is classified clinically into disciform, diffuse, and linear variants according to the distribution of keratic precipitates and stromal oedema. Although the exact pathogenesis remains incompletely defined, current evidence supports a combined mechanism involving direct low-grade viral cytopathic injury to endothelial cells together with a host cell-mediated hypersensitivity response, a hypothesis reinforced by the disorder's characteristic responsiveness to corticosteroid therapy. Diagnosis is primarily clinical, supported where necessary by polymerase chain reaction analysis of aqueous humour, in vivo confocal microscopy, and specular microscopy, particularly when distinguishing HSV endotheliitis from varicella-zoster virus and cytomegalovirus endotheliitis and other causes of endothelial dysfunction. Management combines systemic antiviral therapy with judiciously tapered topical corticosteroids, guided by the precedent established in the Herpetic Eye Disease Study. Delayed recognition or inadequate treatment can result in progressive, often irreversible endothelial cell loss, secondary glaucoma from trabeculitis, and corneal decompensation requiring keratoplasty. This review synthesises current understanding of the epidemiology, virology, pathophysiology, clinical classification, diagnostic evaluation, and evidence-based management of HSV endotheliitis, and outlines emerging diagnostic and therapeutic directions, including quantitative viral load assessment and imaging-based monitoring of endothelial recovery.

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Conclusion HSV endotheliitis is an immune-mediated inflammatory disorder of the corneal endothelium arising from recurrent herpetic ocular disease, with a pathogenesis combining direct low-grade viral injury and host hypersensitivity. Its clinical recognition, guided by the characteristic combination of corneal oedema, keratic precipitates, and mild anterior chamber reaction, is essential given the endothelium's limited regenerative capacity and the consequent risk of permanent visual morbidity from delayed or inadequate treatment. Dual therapy with systemic antivirals and carefully tapered topical corticosteroids remains the cornerstone of management, supplemented as needed by PCR-based viral confirmation and imaging-based monitoring, particularly in atypical or refractory cases. Continued research into individualized, biomarker-guided treatment strategies holds promise for further reducing the long-term endothelial and visual burden of this condition.

Institutions

• Bangabasi Morning College

  West Bengal, Kolkata

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