Clinical, OCT, and Histopathological Correlation of Unusual Honeycomb Pattern of Descemet Membrane in Herpes Simplex Viral Endotheliitis

Abstract

In this study, we described the correlation of clinical, anterior segment-optical coherence tomography (AS-OCT), and histopathological changes in an immunocompetent patient with polymerase chain reaction (PCR)-proven herpes simplex virus type 1 (HSV-1) endotheliitis, with an unusual honeycomb pattern of Descemet membrane (DM). A 54-year-old gentleman presented with a painless, year-long reduction of vision in the right eye and a best corrected visual acuity of 20/100. Slit lamp examination showed diffuse epithelial microcysts, inferior bullae with an unusual honeycomb appearance, and thickening of the DM. The anterior chamber was quiet, and intraocular pressures were normal throughout. AS-OCT demonstrated epithelial edema and a thickened, hyperreflective DM. The contralateral eye was unremarkable. PCR of aqueous humor was positive for HSV-1 DNA. Topical corticosteroids and oral acyclovir reduced the corneal edema, though the DM changes and the visual deficit persisted, for which the eye underwent combined phacoemulsification with Descemet membrane endothelial keratoplasty (DMEK) after 30 months. The intraoperative aqueous tap was also positive for HSV-1 DNA, and histopathology showed a grossly thickened DM, endothelial cell loss, and guttae-like excrescences. At 5 months, the graft was clear, and vision was 20/25. HSV-1 endotheliitis can follow an indolent and progressive course with “honey-comb pattern” of morphological appearance and thickening of the DM, which does not reverse with antiviral therapy. PCR of aqueous humor confirms the etiology and separates herpes simplex virus from cytomegalovirus. DMEK with perioperative antiviral cover restores vision after adequate disease quiescence.