Corneal and Pupillary Characteristics in Herpetic Anterior Uveitis: Insights from Topography, Specular Microscopy, and Pupillometry

Purpose To investigate corneal and pupillary characteristics in herpetic anterior uveitis (HAU) caused by herpes simplex virus (HSV), varicella-zoster virus (VZV) and cytomegalovirus (CMV) using corneal densitometry, specular microscopy, and automated pupillometry.Methods In this prospective study, 56 patients (112 eyes) diagnosed with HAU were categorized into CMV-associated anterior uveitis (CMV-AU, n = 21) and non-CMV HAU (HSV or VZV, n = 35) groups. Corneal transparency was assessed by Scheimpflug-based densitometry. Endothelial cell morphology was evaluated with specular microscopy. Static and dynamic pupillometry measured pupillary responses under various lighting conditions. Clinical features and ocular findings were compared between groups and with contralateral healthy eyes.Results Non-CMV HAU patients demonstrated significantly increased corneal densitometry values indicating stromal haze (p < 0.05) and pupillary constriction deficits compared to fellow eyes (p < 0.05). In contrast, CMV-AU eyes showed significant endothelial cell loss and increased cell size variability (p < 0.05), with relatively preserved corneal transparency. Pupillometry revealed prolonged constriction duration and shortened dilation duration in CMV-AU (p < 0.05). Iris atrophy and posterior synechiae were more frequent in non-CMV HAU. No significant pupillometric differences were observed between CMV and non-CMV groups.Conclusions CMV-AU predominantly affects corneal endothelium with endothelial cell loss and altered pupillary dynamics, whereas HSV/VZV-associated HAU leads to stromal corneal haze and sphincter dysfunction. Quantitative imaging and functional assessments provide complementary, noninvasive parameters that may support clinical differentiation among HAU subtypes.