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

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.