Coin-shaped corneal endothelial scar in herpes zoster ophthalmicus: a case report

Herpes zoster ophthalmicus includes a wide spectrum of lesions at the ocular surface, including epithelial, stromal, endothelial keratitis, and uveitis. Thus far, the occurrence of corneal endothelial disorder in herpes zoster ophthalmicus and the causative virus have not been confirmed, and the differential diagnosis and establishment of therapeutic strategies are challenging. Corneal endothelial coin-shaped lesions are well known to occur in cytomegalovirus-related corneal endotheliitis but have not been reported in patients with herpes zoster ophthalmicus.

A 39-year-old Asian female was referred to our ophthalmology department with recurrent anterior uveitis accompanied by coin-shaped corneal endothelial scar-like lesions that appeared after right facial herpes zoster. Diffuse corneal stromal haziness was mostly limited in the anterior stroma. The coin-shaped corneal endothelial lesions were separate from stromal lesions and showed a high-reflective scar-like line in sections of anterior segment optical coherence tomography. Anterior uveitis recurred each time she discontinued oral antiviral drug treatment for 12 months after the first event, but was remitted by the maintenance medications of combined topical ganciclovir gel with oral valaciclovir, at a dose lower than the usual adult dose, for acute or recurrent zoster-associated anterior uveitis. Corneal endothelial function remained normal and corneal endothelial and stromal lesions were unchanged throughout the treatment and follow-up period.

In patients with a history of facial herpes zoster with coin-shaped corneal endothelial scar accompanying recurrent anterior uveitis, suspicion for active varicella-zoster virus is warranted, and prolonged intake of oral antiviral agents is required despite varicella-zoster virus DNA not being detected in aqueous humor.