Anterior Segment OCT Features of Cytomegalovirus Endotheliitis Mimicking Graft Rejection After DSAEK: Report of Two Cases and Diagnostic Implications.

Purpose: The purpose of the study is to describe anterior segment optical coherence tomography (AS-OCT) findings in cytomegalovirus (CMV) endotheliitis occurring after Descemet stripping automated endothelial keratoplasty (DSAEK) and to emphasize their role in the differential diagnosis between viral endotheliitis and immune-mediated graft rejection. Methods: Two cases of CMV-associated endotheliitis following uneventful DSAEK were retrospectively analyzed. Clinical presentation, intraocular pressure changes, AS-OCT features, virological assessment by aqueous humor polymerase chain reaction (PCR), treatment, and outcomes were evaluated. Results: Both patients developed postoperative graft dysfunction characterized by corneal edema, Descemet membrane folds, and elevated intraocular pressure, initially suggestive of acute allograft rejection. AS-OCT consistently demonstrated a characteristic pattern consisting of graft folds associated with hyperreflective endothelial precipitates, even when slit-lamp examination was limited by severe corneal edema. Aqueous humor PCR testing confirmed CMV DNA in both cases. Targeted antiviral therapy with oral valganciclovir led to resolution of endothelial inflammation and improvement of graft morphology. One patient required repeat endothelial keratoplasty due to irreversible endothelial damage despite virological control. Conclusions: CMV endotheliitis should be considered in cases of atypical graft dysfunction after DSAEK, particularly when associated with elevated intraocular pressure and suboptimal response to corticosteroid therapy. AS-OCT may represent a valuable adjunctive tool in the immunological assessment of endothelial keratoplasty by supporting early recognition of viral endotheliitis and guiding appropriate antiviral management.