Herpetic endothelial dendrite

Ehrenhaus, Michael Phillip MD; Guzman, Sebastian MD

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doi: 10.1097/j.jcro.0000000000000006
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A 70-year-old woman was treated for a protracted epithelial erosion after a second Descemet stripping automated endothelial keratoplasty. Topical antiviral ganciclovir 0.15% was then introduced, and the epithelial defect took on the shape of what appeared to be an epithelial dendritic herpetic keratitis.1 With the antiviral now part of the regimen, the geographic erosion coalesced into true dendrites with terminal bulbs, and with continued treatment, the dendritic epitheliopathy completely resolved. However, once the epithelium healed, a new endothelial dendritic lesion appeared (Figures 1 and 2); however, the overlying corneal stroma remained clear. This new possibly endothelial herpetic keratitis was treated with continued topical and oral antivirals, as well as topical steroids, until complete resolution.

Figure 1.
Figure 1.:
Clear epithelium and nonedematous stroma with the attached and centered endothelial graft with scattered endothelial pigment and the endothelial dendrite noted nasally.
Figure 2.
Figure 2.:
Pigmented endothelial dendrite.


Herpetic keratitis is a well-known entity, with many well-known and documented findings, including endothelial changes seen and reported on biomicroscopy.2,3 Endotheliitis has previously been reported in diffuse, disciform, sectoral, and linear fashions with associated overlying or peripheral edema, with the linear form originating at the limbus and crossing the graft–host junction.4,5

To our knowledge, this is the first case of a reported endothelial dendrite that occurred subsequent to an epithelial herpetic corneal infection, with the appearance of a dendritic lesion that occurred “free standing” without any contiguous extension from the limbus or associated peripheral edema. Our case involved a woman recovering from her second endothelial transplant with the recovery complicated by herpetic epithelial keratitis.

Although laboratory proof was not obtained, because of the highly suggestive etiology of the endothelial lesion, in relation to her previous corneal infection, we treated the case as a herpetic infection with continued antivirals and not simply steroids alone. We think that it is highly probable that the endothelial changes in this case represent a herpetic endothelial dendrite, however, in a varied form from those previously reported in a linear fashion extending from the periphery.


1. Aggarwal S, Cavalcanti BM, Pavan-Langston D. Treatment of pseudodendrites in herpes zoster ophthalmicus with topical ganciclovir 0.15% gel. Cornea 2014;33:109–113
2. Vannas A, Ahonen R. Herpetic endothelial keratitis. A case report. Acta Ophthalmol (Copenh) 1981;59:296–301
3. Vannas A, Ahonen R, Mäkitie J. Corneal endothelium in herpetic keratouveitis. Arch Ophthalmol 1983;101:913–915
4. Moshirfar M, Murri MS, Shah TJ, Skanchy DF, Tuckfield JQ, Ronquillo YC, Birdsong OC, Hofstedt D, Hoopes PC. A review of corneal endotheliitis and endotheliopathy: differential diagnosis, evaluation, and treatment. Ophthalmol Ther 2019;8:195–213
5. Olsen TW, Hardten DR, Meiusi RS, Holland EJ. Linear endotheliitis. Am J Ophthalmol 1994;117:468–474
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