Purpose: To report 2 cases of herpes simplex virus (HSV) stromal keratitis with epithelial ulceration that were managed using optical coherence tomography-generated pachymetric and corneal epithelial thickness maps.

Methods: Two patients with a history of HSV keratitis with nonhealing epithelial defects were referred to the Athens Vision Eye Institute. Anterior segment optical coherence tomography-generated pachymetric and corneal epithelial thickness maps showed subclinical stromal edema and irregular epithelium, thus indicating diagnoses of HSV stromal keratitis with epithelial ulceration. The patients were administered topical preservative-free dexamethasone and oral antiviral therapy. Steroid tapering was guided by pachymetric and corneal epithelial thickness maps at each follow-up visit.

Results: Both patients experienced initial healing of the epithelium and resolution of stromal inflammation. One patient had a recurrence of HSV stromal keratitis with epithelial defect 3 months after initial improvement, with pachymetric and corneal epithelial thickness maps indicating subclinical stromal edema. He was reintroduced to topical steroid therapy, and the stromal edema and epithelial defect subsequently resolved. Both patients have had no recurrences in the past year.

Conclusions: Pachymetric and corneal epithelial thickness maps provide an objective assessment of stromal inflammation and the following 2 clinical advantages in the management of HSV stromal keratitis with epithelial ulceration: (1) they help differentiate it from HSV epithelial keratitis with geographic ulceration and neurotrophic keratopathy and (2) offer objective measurements to guide management with topical corticosteroids until resolution of stromal edema. Thus, treatment can be initiated in a timely manner, and the blinding complications of HSV stromal keratitis can be avoided.