Successful treatment of progressive outer retinal necrosis syndrome

PURPOSE

Progressive outer retinal necrosis is a destructive retinopathy found in patients with acquired immune deficiency syndrome. Treatment of this disorder has been unsuccessful in reported patient series, with the patients experiencing profound bilateral loss of vision.

METHODS

We treated six patients with combination antiviral therapy, usually with intravenous foscarnet and either ganciclovir or acyclovir.

RESULTS

These six patients retained a visual acuity of 20/100 or better in at least one eye for the remainder of their lives (a period > 4 months for each patient). Retinal detachments developed in four patients, for which vitrectomy and silicone oil tamponade were required.

CONCLUSIONS

A combination of intravenous antiviral therapy and aggressive vitrectomy techniques to repair any associated detachments may allow the preservation of useful visual acuity in patients with progressive outer retinal necrosis. This is the first reported series of successful long-term treatment of patients with this disorder.

Progressive outer retinal necrosis (PORN) in AIDS patients: a different appearance of varicella-zoster retinitis

Retinal infections caused by the varicella-zoster virus (VZV) have been reported in immunocompetent and immunocompromised individuals. Two cases of a VZV-related retinitis are described with the characteristic features of the recently described progressive outer retinal necrosis (PORN) syndrome. Both patients suffered from the acquired immunodeficiency syndrome (AIDS) with greatly reduced peripheral blood CD4+ T lymphocyte counts, and presented with macular retinitis without vitritis. The disease was bilateral in one case and unilateral in the other. The clinical course was rapidly progressive with widespread retinal involvement and the development of rhegmatogenous retinal detachment with complete loss of vision in the affected eyes despite intensive intravenous antiviral therapy. VZV DNA was identified in vitreous biopsies, by molecular techniques based on the polymerase chain reaction (PCR), in both patients. At present, the use of very high-dose intravenous acyclovir may be the best therapeutic option in these patients for whom the visual prognosis is poor. Intravitreal antiviral drugs could also contribute to the management of these cases.

Ocular inoculation of monkeys with simian varicella virus: clinical and histopathologic observations

PURPOSE

To explore the possibility that inoculation of the eyes of African green monkeys with simian varicella virus (SVV) induces the symptoms of herpes zoster ophthalmicus (HZO), as seen in humans, and to develop a realistic and reproducible animal model of herpes zoster ophthalmicus for experimental studies.

METHODS

In the first experiment, the right eyes of three African green monkeys were inoculated by intrastromal and subconjunctival injections with a suspension of SVV-infected Vero cells. In the second experiment, three additional monkeys were pretreated with intramuscular injections of methylprednisolone (41 mg/kg) for 7 days before ocular inoculation with SVV and for 3 weeks at 14 mg/kg after virus inoculation. The eyes were examined by slit-lamp biomicroscopy. Histologic, immunohistochemical, and electron microscopic studies were performed.

RESULTS

In the first experiment, all three animals developed high titers of anti-SVV antibodies (IgG). Diffuse stromal opacity, with keratitic precipitates, stromal edema, and mild vascularization of the cornea, appeared 12 to 14 days after inoculation. The onset of ocular disease was correlated with the rise in serum antibody levels. There was no clinical evidence of a systemic viral infection resulting from the corneal inoculations in these monkeys. In the second experiment, all three animals treated with methylprednisolone developed severe ocular pathology within 1 week of inoculation. The clinical appearance of the diseased eyes strongly indicated that local viral infection had occurred. Dendritiform keratitis, corneal erosion, and stromal necrosis with vascularization of the cornea was seen in all the eyes. The disease resolved within 4 to 5 weeks of inoculation, leaving opaque, vascularized corneas. Histologic studies showed that inflammatory cells and viral antigens were widespread throughout the diseased corneas. A high titer of anti-SVV antibody (IgG) was detected in the immunosuppressed monkeys, but no evidence of systemic viral infection was observed.

CONCLUSIONS

The authors propose that inoculation of the eyes of methylprednisolone-treated African green monkeys with simian varicella virus provides an appropriate animal model for studies of the virology and immunopathology of ocular varicella virus infection.

Progressive outer retinal necrosis secondary to varicella zoster virus in acquired immune deficiency syndrome

BACKGROUND

A syndrome consisting of rapidly progressive outer retinitis in patients with suppressed immune systems has been described. The etiologic agent appears to be a member of the herpes virus family.

METHODS

A 41-year-old man with acquired immune deficiency syndrome (AIDS) developed bilateral outer retinitis and choroiditis, which progressed despite antiviral treatment. A transscleral eye wall biopsy specimen and whole globe were submitted for microbiologic and histologic study.

RESULTS

Polymerase chain reaction of a transscleral eye wall biopsy specimen and of the enucleated specimen determined the etiologic agent to be varicella zoster virus (VZV). Histologic studies demonstrated intranuclear inclusions consistent with viral particles in choroidal cells.

CONCLUSION

Our study revealed intranuclear inclusions in choroidal cells, a previously undocumented finding in progressive outer retinal necrosis. Polymerase chain reaction was very useful in identifying the causative agent.

[Rapidly progressive outer retinal necrosis in a patient with acquired immunodeficiency syndrome]

We report a case of rapidly progressive varicella zoster virus retinitis, which is distinct from acute retinal necrosis syndrome. The patient was a 52-year-old male and suffered acquired immunodeficiency syndrome. Two months after the varicella zoster dermatitis in the distribution of the first division of the left trigeminal nerve, pseudodendritic keratitis and iridocyclitis were observed in the left eye. After 5 weeks, multifocal and patchy white exudates were observed in the peripheral deeper layer of the retina in the left eye, but retinal vasculitis in the exudative lesions was slight. Despite systemic administration of acyclovir, white exudates progressed confluently from the periphery to the post pole of the retina and reached the macula in 10 weeks. Eight weeks after the observation of lesions in the left eye, we found the same lesions in the right eye. After the white exudative lesions disappeared, the retina became atrophic and the retinal vessels were narrowed, but no retinal detachment was observed. Recently, Foster and associates described the rapidly progressive outer retinal necrosis as a new entity of varicella zoster virus retinitis in AIDS patients. We think our case was very similar to the rapidly progressive outer retinal necrosis. This case shows that we must carefully follow up the rapidly progressive outer retinal necrosis in the AIDS patients with a varicella zoster dermatitis.

Orbital disease in herpes zoster ophthalmicus

Three cases of orbital inflammatory disease caused by herpes zoster are described. This extremely rare complication occurred between 5 days and 14 days following the skin eruption and slowly resolved with or without treatment. Biopsy of a chronic inflammatory lesion on the cheek of one patient demonstrated a sterile vasculitis and granulomatous liponecrosis, a process which may underlie the orbital disease in these patients.

The progressive outer retinal necrosis syndrome. A variant of necrotizing herpetic retinopathy in patients with AIDS

BACKGROUND

The progressive outer retinal necrosis syndrome is a recently recognized variant of necrotizing herpetic retinopathy. This report characterizes more fully its clinical features and course.

METHODS

Using standardized clinical criteria, patients with progressive outer retinal necrosis syndrome from four institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, presenting symptoms, physical findings, course, responses to treatment, and outcomes.

RESULTS

Thirty-eight patients (65 involved eyes) were studied. All had acquired immune deficiency syndrome. A known history of cutaneous zoster was documented in 22 (67%) of 33 patients. Median CD4 lymphocyte count was 21/mm3 (range, 0-130/mm3). Median follow-up was 12 weeks. The most common presenting symptom was unilateral decreased vision (35 of 65 eyes, 54%); median visual acuity at presentation was 20/30 (range, 20/20 to no light perception [NLP]). Anterior chamber and vitreous inflammatory reactions were absent or minimal in all patients. Typical retinal lesions were multifocal, deep opacities scattered throughout the periphery, although macular lesions also were present in 21 eyes (32%) at diagnosis. Lesions progressed rapidly to confluence. Initial intravenous antiviral therapy appeared to reduce disease activity in 17 (53%) of 32 eyes, but treatment did not alter final visual outcome. Visual acuity was NLP in 42 (67%) of 63 eyes within 4 weeks after diagnosis. Retinal detachment occurred in 43 (70%) of 61 eyes, including 13 (93%) of 14 eyes that received prophylactic laser retinopexy.

CONCLUSION

The progressive outer retinal necrosis syndrome is characterized by features that distinguish it from cytomegalovirus retinopathy, acute retinal necrosis syndrome, and other necrotizing herpetic retinopathies. Visual prognosis is poor with current therapies.

[Varicella zoster virus infections of the retina in patients with and without immune suppression]

BACKGROUND

Infections of the retina with the varicella-zoster virus can lead to severe visual impairment. Patients with immunodeficiency are particularly predisposed to viral infections, and the alterations of the immune system may lead to a modified clinical picture.

PATIENTS

Two cases of infections of the retina with the varicella-zoster virus in an immunocompromised and an immunocompetent patient are presented. The first otherwise healthy patient showed the typical clinical picture of the "acute retinal necrosis syndrome" with orbital pain and decrease of vision. He had inflammatory infiltration of the vitreous and the anterior chamber, retinal vasculitis, optic disc edema and whitening of the peripheral retina with full thickness retinal necrosis. The second patient with AIDS presented with a history of sudden painless loss of vision in one eye. He had a swollen optic disc, inflammatory infiltrates in the choroid and virtually no cellular infiltration of the vitreous or the anterior chamber. The diagnosis of varicella-zoster virus infection of the retina was confirmed in both patients by polymerase chain-reaction of aqueous and vitreous humor, by determination of intraocular antibody titers and immunohistochemistry on retinal biopsy material, respectively. In both patients no inflammation in the fellow eye developed under therapy with aciclovir. The first patient regained full vision after vitrectomy with membrane dissection.

CONCLUSIONS

Varicella-zoster virus infections of the retina can present with different clinical pictures in immunocompromised and immunocompetent patients. Early diagnosis and adequate medical and surgical therapy can significantly improve visual prognosis.

Ophthalmic herpes zoster

A current review of ophthalmic zoster is presented including its virology, immunology, epidemiology and pathogenesis. We give our findings in 1356 patients referred to the Zoster Clinic at Moorfields Eye Hospital, London. The treatment of the disease and its ocular complications is discussed.

Herpes zoster ophthalmicus with orbital pseudotumor syndrome complicated by optic nerve infarction and cerebral granulomatous angiitis: MR-pathologic correlation

The authors describe a 41-year-old woman with herpes zoster ophthalmicus and extensive intracranial and orbital involvement as documented by MR and pathologically. MR showed all of the lesions that led to the ophthalmoplegia and pseudotumor syndrome, the periaxial infarct of the distal optic nerve, pontine infarcts, and granulomatous angiitis of the meningeal vessels. MR is useful in both detection and monitoring of the disease.

[Erosive pustular dermatosis of the scalp after zoster ophthalmicus and trauma]

Erosive pustular dermatosis of the scalp (EPDS), first described in 1979, is a rare, chronic, pustular condition with scarring alopecia, and nonspecific histological findings. While the initial responded to steroids is good, it can be treated successfully by oral administration of zinc sulphate. Local trauma has recently been suggested to play a role in the pathogenesis of EPDS. The differential diagnosis of EPDS includes folliculitis decalvans, sterile eosinophilic pustulosis Ofuji, pustular psoriasis vulgaris, trichophytosis, Perifolliculitis capitis abscedens et suffodiens, pemphigus vulgaris and cicatricial pemphigoid. We present the cases of a 74-year-old woman suffering from EPDS following herpes zoster ophthalmicus and of a 54-year-old man in whom EPDS followed a head injury.

Dual appearance of fluorescein staining in vivo of diseased human corneal epithelium. A non-contact photomicrographic study

Adherence of fluorescein sodium dye to diseased epithelial cells, a hitherto unreported phenomenon, was captured in photomicrographs in severe herpes zoster and keratoconjunctivitis sicca keratopathies. It is notable that this phenomenon differs completely from the well known fluorescent property of the dye penetrating into defective corneal epithelium, and that the staining pattern shown by adherent fluorescein correlates well with the staining pattern shown by rose bengal dye.

Clinical profile of herpes zoster ophthalmicus

Herpes zoster ophthalmicus was seen in 22 cases out of 195 cases of herpes zoster (11.3% incidence). It was affecting mainly adults (90.9%). Oedema over the lids (81.8%) was invariably present and lead to ptosis. Mucopurulent conjunctivitis, predominantly mucoid (72.7%) was the commonest manifestation associated with vesicles over the lid margins. Sectorial (22.7%) and diffuse (9.1%) episcleritis appeared in later part of first week, while nodular episcleritis was observed in one case only on 12th day of the disease. Nummular keratitis was seen in 31.8% of cases between 8-10 days. Iritis and iridocyclitis was seen in 45.4% of cases out of which 36.3% had secondary ocular hypertension (glaucoma). Neuroparalytic keratitis and internal ophthalmoplegia were detected in one patient each. Postherpetic neuralgia occurred in 22.7% of cases and was uncommon in younger age group (below 40 years, 4.5%). Carbamazepine was effective in relieving the herpetic pain.

Herpes Zoster Ophthalmicus in a child with acquired immune deficiency syndrome

A case is described of an 8 year old child who presented with Herpes Zoster Ophthalmicus involving the left eye. He had a positive history of pulmonary tuberculosis, repeated hospital admissions and blood transfusion. He was confirmed to have Acquired Immune Deficiency Syndrome. During the course of his followup, he developed cotton-wool spots and perivasculitis in the right eye. The mother was found to be seropositive while the father was seronegative.

Cutaneous eruption with or without ocular complications in patients with herpes zoster involving the trigeminal nerve

We examined 62 patients with acute herpes zoster involving the trigeminal nerve; 13 had eruptions only and 49 (51 eyes) had eruptions with ocular complications. Bilateral involvement was found in two patients. The frequency of the disease appeared to increase with age, and the disease was least active in November. Patients with eruptions only demonstrated affected areas along the first, second, and/or third divisions of the trigeminal nerve. Ocular complications occurred in patients who had eruptions along the first and/or second divisions of the nerve, and they were usually noted in patients with eruptions on the tip and one side of the node. The ocular complications and associated systemic conditions varied.

Herpes zoster ophthalmicus with delayed contralateral hemiparesis

A 35-year-old previously healthy woman developed left hemiparesis sixteen weeks after the onset of right herpes zoster ophthalmicus. Cerebral angiography showed complete occlusion of right middle cerebral artery at the origin and segmental narrowing of the right posterior cerebral artery. Computerized tomography (CT) and magnetic resonance imaging (MRI) also revealed a right hemispheric lesion consistent with angiographic findings. Reports from the literature along with the present case suggest that arteritis followed by cerebral infarction is the most probable cause of delayed contralateral hemiparesis.

Contralateral hemiplegia in herpes zoster ophthalmicus. Role of temporal artery biopsy

We describe clinical, radiological and pathological findings in a case of herpes zoster ophthalmicus who developed contralateral hemiplegia. The CT scan showed discrete infarction of the right internal capsule and the right carotid angiogram showed concentric narrowing of the supraclinoid portion of right internal carotid artery. Superficial temporal artery biopsy showed infiltration by lymphocytes and plasma cells without any granuloma formation or giant cells. The importance of trigemino-vascular connections in the pathogenesis of this complication of herpes zoster ophthalmicus and the role of temporal artery biopsy in the diagnosis of arteritis following herpes zoster are discussed.

Herpes ophthalmicus

Always ensure that patient consent is obtained before any type of photography is undertaken, as the patient has the right to decide what is to happen to the images.

Ocular varicella-zoster virus infection in the guinea pig. A new in vivo model

Corneal intrastromal inoculation of guinea pigs with approximately 10(4) plaque-forming units of live, adapted varicella-zoster virus (VZV) resulted in reproducible, acute, superficial corneal disease in all animals. The culture-positive VZV ocular infection progressed to involve 30% to 40% of the corneal surface in a diffuse punctate keratitis and 10% to 15% of this surface with microdendrites, characteristic of VZV-induced ocular disease. Retrograde dissemination of VZV to the trigeminal ganglia, midbrain, cerebellum, and superior cervical ganglia was demonstrated by whole-cell coculture VZV recovery. Central nervous system VZV dissemination, manifested by transient neurologic symptoms and pneumonitis, was evident in 60% of the animals. Varicella-zoster virus spread to the trigeminal ganglion during acute and early-latent infection was evident by electron microscopy.

[Acute necrotizing retinitis following varicella zoster virus infection]

As far as we know today, acute retinal necrosis is caused by infection with a virus of the herpes group. Reports are occasionally published of retinitis developing before or after herpes zoster dermatitis. The present paper reports the case of a patient who developed a retinitis of the right eye five years after a herpes zoster infection of the ophthalmic nerve. Studies and treatment of VZV retinitis and retinitis before or after zoster retinitis reported in the literature are summarized. The possible mechanisms of generalization (neurogenic or hematogenous) are analyzed.