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Al Saraiji H, Alshaweesh L, Hemling S, Gerl M. Ultrawidefield imaging aids in the early detection and management of acute retinal necrosis. BMJ Case Rep 2024; 17:e255262. [PMID: 39179261 DOI: 10.1136/bcr-2023-255262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2024] Open
Abstract
Acute retinal necrosis (ARN) is a rare and rapidly progressive disease characterised by the development of panuveitis and peripheral retinal lesions. These lesions can often be missed during a routine fundoscopic examination, making the early diagnosis of ARN a considerable challenge. This case report describes the utilisation of ultrawidefield (UWF) imaging in the early detection of peripheral lesions associated with ARN in a male patient in his late 60s, who presented with acute blurred vision and a documented history of herpes zoster ophthalmicus. During a comprehensive eye examination and UWF imaging, panuveitis and peripheral lesions were identified, eventually leading to a diagnosis of ARN. The early initiation of antiviral therapy led to a gradual clinical improvement over 3-4 months. The utilisation of serial UWF imaging played a critical role in the prompt diagnosis and effective monitoring of disease progression, thereby potentially improving the patient's outcome.
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Akhavanrezayat A, Uludag Kirimli G, Matsumiya W, Khojasteh H, Or C, Karaca I, Pham B, Ongpalakorn P, Lajevardi S, Lam B, Hwang JJ, Than NTT, Park S, Yavari N, Bazojoo V, Mobasserian A, Khatri A, Halim MS, Thng ZX, Ghoraba H, Do DV, Tugal-Tutkun I, Gupta V, de Smet M, Nguyen QD. The Role of Corticosteroids and Immunomodulatory Therapy in the Management of Infectious Uveitis. Ocul Immunol Inflamm 2024:1-12. [PMID: 38330155 DOI: 10.1080/09273948.2023.2296032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/11/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE The index review aims to provide an update on the role of corticosteroids and steroid-sparing immunomodulatory therapy (IMT) in managing patients with infectious uveitis. METHOD Narrative literature review. RESULTS Corticosteroids and immunomodulatory therapy (IMT) focus on the host defense system instead of the pathogen, adjusting exaggerated inflammatory reactions to reduce potential harm to ocular tissues. Systemic or local corticosteroids are primarily selected as adjunctive medication for infectious uveitis. Concomitant corticosteroids have also been used in cases of paradoxical worsening in ocular tuberculosis and immune recovery uveitis in cytomegalovirus (CMV) retinitis. While there is no well-established evidence to support the use of IMT in infectious uveitis, it is occasionally used in clinical settings to treat persistent inflammation following resolution of infection such as cases of ocular tuberculosis and ocular syphilis where an insufficient response is observed with corticosteroids. CONCLUSION There is no consensus on the position of immunomodulatory therapy in the management of infectious uveitis with different etiologies. The index review provides an overview of available adjunctive corticosteroids and IMT options to assist clinicians in managing such disease entities more efficiently.
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Affiliation(s)
- Amir Akhavanrezayat
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Gunay Uludag Kirimli
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hassan Khojasteh
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christopher Or
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Irmak Karaca
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Pham
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | | | - Sherin Lajevardi
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Brandon Lam
- Department of Ophthalmology, University of Texas Health Science Center, San Antonio, Texas, USA
| | - Jaclyn Joyce Hwang
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ngoc Trong Tuong Than
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - SungWho Park
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Negin Yavari
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vahid Bazojoo
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Azadeh Mobasserian
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Anadi Khatri
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Zheng Xian Thng
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Hashem Ghoraba
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Faculty of Medicine, Istanbul University, Istanbul, Turkey
- Bayrampasa Eye Hospital, Eye Protection Foundation, Istanbul, Turkey
| | - Vishali Gupta
- Advanced Eye Center, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Marc de Smet
- Department of Ophthalmology, MicroInvasive Ocular Surgery Clinic (MIOS), Lausanne, Switzerland
| | - Quan Dong Nguyen
- Byers Eye Institute, Stanford University School of Medicine, Palo Alto, California, USA
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Sanjay S, Sharief S, Joshi A, Yadav NK. Long-term follow-up of acute retinal necrosis with retinal detachment secondary to herpes simplex virus type 2 with a successful visual outcome. BMJ Case Rep 2023; 16:e252913. [PMID: 37185312 PMCID: PMC10151916 DOI: 10.1136/bcr-2022-252913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
A man in his early 20s presented with acute loss of vision in his only eye, the left eye (OS), and was on oral steroids. He had lost vision in his right eye during his childhood and the cause was unknown. There was no history of trauma. Best-corrected visual acuity (BCVA) in OS was 20/100 and in the right eye was hand movements. OS showed non-granulomatous keratic precipitates on the cornea, anterior chamber flare 1+ and cell 1+, early cataract, vitreous haze and cells 2+ with nasal retinal detachment and superior full thickness retinitis. He underwent pars plana vitrectomy with intravitreal ganciclovir and barrage laser away from the necrotic retina. PCR for herpes simplex virus 2 was positive from the aqueous and vitreous sample. He was started on oral valacyclovir 1 g three times a day and continued on tapering dose of oral steroids. BCVA in OS at 6-month follow-up was 20/25.
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Affiliation(s)
- Srinivasan Sanjay
- Uveitis and Ocular Immunology, Narayana Nethralaya, Bangalore, India
| | - Shama Sharief
- Vitreo-retina, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Aishwarya Joshi
- Uveitis and Ocular Immunology, Narayana Nethralaya, Bangalore, India
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Helal RS, Abu Sbeit R, Al-Baker ZM. Unusual pattern of herpetic optic neuropathy: a case report and literature review of the pathophysiology of herpetic uveitis. J Ophthalmic Inflamm Infect 2023; 13:12. [PMID: 36943518 PMCID: PMC10030693 DOI: 10.1186/s12348-023-00335-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 03/02/2023] [Indexed: 03/23/2023] Open
Abstract
Herpetic uveitis is a relatively common type of intraocular inflammation with a broad spectrum of manifestations ranging from mild anterior uveitis to rapidly progressing vision threatening necrotizing retinitis. Posterior herpetic uveitis presents with different clinical patterns within a spectrum depending presumably on the immune status of the patient. Systemic steroid use for viral uveitis without prior antiviral coverage is inappropriate and can lead to dramatic sequelae. Here, we report an unusual case of herpetic optic neuropathy in the contra lateral eye of a patient with acute retinal necrosis after improper use of oral steroids.
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Affiliation(s)
| | - Rami Abu Sbeit
- Ophthalmology Department, Hamad Medical Corporation, Doha, Qatar
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Loubsens E, Adam R, Debard A, Barioulet L, Varenne F, Fournié P, Sales de Gauzy T, Ollé P, Martin-Blondel G, Soler V. First-line management of necrotizing herpetic retinitis by prioritizing the investigation of immune status and prognostic factors for poor visual outcomes. Int Ophthalmol 2023:10.1007/s10792-023-02656-8. [PMID: 36920634 DOI: 10.1007/s10792-023-02656-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 02/19/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE To review management, treatment, and outcomes of patients with necrotizing herpetic retinitis (NHR) to propose an algorithm for first-line management of NHR. METHODS Retrospective evaluation of a series of patients with NHR at our tertiary center between 2012 and 2021 using demographic, clinical, ophthalmologic, virological, therapeutic, and prognostic characteristics was performed. Patients were classified by NHR type: acute retinal necrosis (ARN), progressive outer retinal necrosis (PORN), cytomegalovirus (CMV) retinitis. RESULTS Forty-one patients with NHR were included: 59% with ARN, 7% with PORN, and 34% with CMV retinitis. All patients with CMV retinitis and PORN were immunocompromised versus 21% of patients with ARN. CMV infection was found in 14 (34%) patients, varicella zoster virus infection in 14 (34%) patients, herpes simplex virus type 2 infection in 8 (20%) and type 1 infection in 5 (12%) patients. Intravenous antiviral therapy was received by 98% of patients and intravitreal antiviral injections by 90% of patients. The overall complication rate during follow-up was 83% of eyes. Most frequent complications were retinal detachment (33% eyes) and retinal break (29% eyes). Prognostic factors for poor visual outcomes were pre-existing monocular vision loss in contralateral eye among 17% of patients, bilateral NHR in 17% of patients, posterior pole involvement in 46% of eyes, and involvement > 2 retinal quadrants in 46% of eyes. CONCLUSIONS The visual prognosis of patients with NHR remains poor. Prompt investigation of immune status and presence of factors justifying intravitreal antiviral injections must be prioritized to initiate and adapt management while awaiting causative virus confirmation.
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Affiliation(s)
- Emmanuelle Loubsens
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Raphaël Adam
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Alexa Debard
- Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France
| | - Lisa Barioulet
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Fanny Varenne
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Pierre Fournié
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France.,University of Toulouse III, Toulouse, France
| | - Thomas Sales de Gauzy
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Priscille Ollé
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France
| | - Guillaume Martin-Blondel
- Department of Infectious and Tropical Diseases, Toulouse University Hospital, Toulouse, France.,University of Toulouse III, Toulouse, France.,INSERM U1043-CNRS UMR 5282, Centre for Physiopathology of Toulouse-Purpan, Toulouse, France
| | - Vincent Soler
- Ophthalmology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, CHU Toulouse, Place Baylac, 31059, Toulouse, France. .,University of Toulouse III, Toulouse, France.
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Aksu-Ceylan N, Güner ME, Cebeci Z, Altınkurt E, Kır N, Oray M, Tugal-Tutkun İ. Association Between Prognosis of Acute Retinal Necrosis and Retinal Involvement. Turk J Ophthalmol 2022; 52:405-411. [PMID: 36578219 PMCID: PMC9811224 DOI: 10.4274/tjo.galenos.2021.58609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objectives The aims of this study were to describe the clinical presentation and treatment modalities of acute retinal necrosis (ARN) and to evaluate complications and clinical outcomes according to the extent of retinal involvement at initial presentation. Materials and Methods The medical records of 52 patients diagnosed with ARN were reviewed and 48 were included in the study. Patients were categorized into two groups according to the extent of retinitis at presentation: retinal involvement of 1-2 quadrants (Group A) or 3-4 quadrants (Group B). Results The mean age of the 14 women and 34 men at presentation was 51.3±13.6 years (range: 27-78). There were 40 unilateral and 8 bilateral cases. There were 11 eyes (19.6%) in Group A and 45 eyes (80.4%) in Group B. Eleven patients (22.9%) had a history of herpes simplex virus/varicella-zoster virus infection. One patient in Group A and 11 patients in Group B had received local or systemic corticosteroid therapy without concomitant antiviral treatment before referral. The median follow-up period was 29 months (range: 1-209) in Group A and 8.5 months (range: 0.75-209) in Group B. Mean visual acuity (VA) at presentation was 0.42±0.55 LogMAR (range: 0-2.0) in Group A and 1.28±0.95 LogMAR (range: 0-2.9) in Group B (p<0.05). The presence of endothelial keratic precipitates at presentation was significantly different between two groups (p=0.021). Retinal detachment (RD) occurred in 1 eye (9.1%) in Group A and 30 eyes (66.7%) in Group B (p<0.001). Optic disc pallor was seen in 36.4% (4/11) of eyes in Group A and 71.1% (32/45) of eyes in Group B (p=0.033). Other ocular complications were not significantly different between two groups. Mean final visual acuity was 0.29±0.41 LogMAR in Group A and 1.61±0.90 LogMAR in Group B (p<0.05). Conclusion The extent of retinal involvement at presentation affects visual outcomes and this shows the importance of early diagnosis and early initiation of antiviral treatment.
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Affiliation(s)
- Nihan Aksu-Ceylan
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey,* Address for Correspondence: İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey E-mail:
| | - Mehmet Eren Güner
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - Zafer Cebeci
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - Emre Altınkurt
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - Nur Kır
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - Merih Oray
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
| | - İlknur Tugal-Tutkun
- İstanbul University, İstanbul Faculty of Medicine, Department of Ophthalmology, İstanbul, Turkey
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Hojjatie S, Shantha JG, O’Keefe GD, Kraft CS, Voloschin A, Grossniklaus H, Yeh S. Cytopathology of Vitreous Specimens in Acute Retinal Necrosis. Ocul Immunol Inflamm 2022; 30:1609-1616. [PMID: 34242097 PMCID: PMC8742848 DOI: 10.1080/09273948.2021.1922926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/27/2021] [Accepted: 04/19/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE To report the cytopathology of vitreous biopsy samples in patients with acute retinal necrosis (ARN) who underwent pars plana vitrectomy (PPV). We also describe two patients with unique clinical courses, cytopathologic findings, and immune response. METHODS A retrospective review of patients with ARN who developed retinal detachment (RD) and underwent PPV from 22011 to 2019 at the Emory Eye Center was performed to assess cytopathology findings of vitreous biopsy samples. Patient demographics and laboratory testing including aqueous humor PCR for viral pathogens were recorded. Additional clinical details abstracted included intravitreal injections, surgical procedures, and vitreous cytopathological reports including immunohistochemistry findings. RESULTS Fourteen eyes of 12 patients with RD were reviewed. Ten eyes showed HSV DNA (71%) and 4 demonstrated VZV DNA (29%). All eyes received intravitreal antivirals (i.e. ganciclovir or foscarnet) with a median of 8.5 intravitreal injections per eye. Diagnoses prompting PPV included tractional RD in 14 eyes (100%), rhegmatogenous RD in 8 eyes (57%), vitreous hemorrhage in 4 eyes (29%) and vitreous opacity in 4 (29%). Ophthalmic pathology reports showed lymphocyte populations in 10 eyes (71%) with a CD3 + T-cell predominance in two patients where immunohistochemistry of CD3+ and CD20+ for T- and B-cell populations was performed. Observed immune cell populations included macrophages or histiocytes (11 eyes, 79%) and polymorphonuclear cells in 4 eyes (29%). Initial median VA was 2.5 (IQR 2.0-3.0) and improved to 2.0 (IQR 1.48-3.00, p = .48) at 6-months and 1.8 (IQR 1.2-3.0, p = .45) at 12 months follow-up. CONCLUSIONS Our cohort of ARN patients undergoing PPV show a spectrum of immunologic findings with the majority demonstrating a lymphocytic response. Histiocytes, macrophages, and PMNs were also observed. Cytopathologic and immunologic studies suggest that both innate and adaptive immunity are responsible for the clinical disease findings observed in ARN. The variability of the response to treatment in patients with ARN may reflect patient-to-patient differences in their antigen-specific immune response. Understanding the immunologic response associated with ARN may provide valuable information regarding the dosing and timing of treatment.
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Affiliation(s)
- Sara Hojjatie
- Department of Ophthalmology, University of Washington, Seattle, Washington
| | | | | | - Colleen S. Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Alfredo Voloschin
- Department of Hematology and Oncology, Emory University School of Medicine, Atlanta, GA
| | - Hans Grossniklaus
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
- L.F. Montgomery Pathology Laboratory, Atlanta, GA
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
- Emory Global Health Institute, Emory University, Atlanta, GA
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE
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Abstract
SIGNIFICANCE Acute retinal necrosis is a rare, sight-threatening condition typically found in immunocompromised patients and is most commonly caused by varicella zoster virus. Due to the poor prognosis and rapid progression of the disease course, prompt antiviral management is paramount. PURPOSE A case report of acute retinal necrosis in a patient with herpes virus infection following a cervical epidural corticosteroid injection. Extensive laboratory work and frequent follow-ups are necessary for management. This case report outlines the clinical signs of acute retinal necrosis and discusses the appropriate referrals and treatment needed to improve prognosis. CASE REPORT A 63-year-old man presented to our eye clinic with symptoms of pain and light sensitivity. Examination revealed anterior uveitis, vitritis, optic disc edema, macular edema, vasculitis, and retinitis of the left eye. The serum antibody test results showed abnormal ranges for varicella zoster virus and herpes simplex virus type 1, and the patient was diagnosed with acute retinal necrosis. Treatment prescribed by a retina specialist included oral valacyclovir and later oral prednisolone, for which the patient responded well before developing the common complication of retinal detachment. CONCLUSIONS The progressive nature of acute retinal necrosis is usually debilitating to vision, even when managed properly. Because prognosis is often poor, it is important to make proper diagnoses combined with a complete review of the patient's medical history and immune status to prevent further vision loss.
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Cox JT, Miller JB. Retinal Detachment Associated With Acute Retinal Necrosis. Int Ophthalmol Clin 2022; 62:157-172. [PMID: 35325917 DOI: 10.1097/iio.0000000000000414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dong X, Wee C, Xu D, Wan P. Rare cause of left eye floaters and blurred vision in an immunocompromised patient: acute retinal necrosis (ARN). BMJ Case Rep 2022; 15:e248636. [PMID: 35236705 PMCID: PMC8895929 DOI: 10.1136/bcr-2021-248636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/03/2022] Open
Abstract
Acute retinal necrosis (ARN) is a clinical syndrome featuring severe vitritis and occlusive vasculitis characterised by full thickness necrotising retinitis. ARN is usually caused by an acute infection by either varicella zoster virus or herpes simplex virus, rarely cytomegalovirus (CMV). ARN often occurs in healthy adults; occasionally affecting immunocompromised patients with poor prognosis including significant visual loss and detachment of the atrophic retina regardless of antiviral treatment. We presented a man in his early 30s with a history of left eye floaters and blurred vision. He was diagnosed with T-cell acute lymphoblastic leukaemia 1 year ago and treated with chemotherapy and allogenic haematopoietic stem cell transplant 5 months ago. His clinical diagnosis was left eye ARN caused by acute viral infection with CMV being the most likely cause, which is rarely seen in immunocompromised patients. Our case highlighted a diagnostic and therapeutic challenge in the absence of guideline or evidence-based literature to follow.
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Affiliation(s)
- Xia Dong
- Department of Ophthalmology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Cleo Wee
- Curtin Medical School, Curtin University Bentley Campus, Perth, Western Australia, Australia
| | - Dan Xu
- Curtin Medical School, Curtin University Bentley Campus, Perth, Western Australia, Australia
- Medical Education & General Practice, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Pengxia Wan
- Department of Ophthalmology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
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Classification Criteria for Acute Retinal Necrosis Syndrome. Am J Ophthalmol 2021; 228:237-244. [PMID: 33845012 PMCID: PMC8675365 DOI: 10.1016/j.ajo.2021.03.057] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine classification criteria for acute retinal necrosis (ARN). DESIGN Machine learning of cases with ARN and 4 other infectious posterior uveitides / panuveitides. METHODS Cases of infectious posterior uveitides / panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior uveitides / panuveitides. The resulting criteria were evaluated on the validation set. RESULTS Eight hundred three cases of infectious posterior uveitides / panuveitides, including 186 cases of ARN, were evaluated by machine learning. Key criteria for ARN included (1) peripheral necrotizing retinitis and either (2) polymerase chain reaction assay of an intraocular fluid specimen positive for either herpes simplex virus or varicella zoster virus or (3) a characteristic clinical appearance with circumferential or confluent retinitis, retinal vascular sheathing and/or occlusion, and more than minimal vitritis. Overall accuracy for infectious posterior uveitides / panuveitides was 92.1% in the training set and 93.3% (95% confidence interval 88.2, 96.3) in the validation set. The misclassification rates for ARN were 15% in the training set and 11.5% in the validation set. CONCLUSIONS The criteria for ARN had a reasonably low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.
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RETINAL DETACHMENT AFTER ACUTE RETINAL NECROSIS AND THE EFFICACIES OF DIFFERENT INTERVENTIONS: A Systematic Review and Metaanalysis. Retina 2021; 41:965-978. [PMID: 32932382 DOI: 10.1097/iae.0000000000002971] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To estimate the rate of retinal detachment (RD) after acute retinal necrosis (ARN) and evaluate the efficacies of different interventions. METHODS The databases Medline and EMBASE from inception to March 2020 were searched to identify the relevant studies. R software version 3.6.3 was used to perform the statistical analyses. Results in proportion with 95% confidence interval were calculated using generalized linear mixed models. RESULTS Sixty-seven studies involving 1,811 patients were finally included. The pooling results suggested the general RD rate of ARN was 47%. The RD rate increased with the extent of retinitis and was slightly lower when involved Zone III. The RD rate was 37% for herpes simplex virus ARN and 46% for varicella-zoster virus ARN; 52% for immunocompetent patients and 39% for immunocompromised patients. Retinal detachment presented in 2% of eyes at the first visit. Systemic antiviral therapy could lower the RD rate significantly from 67% to 43%, and prophylactic vitrectomy could lower the RD rate significantly from 45% to 22%. Systemic antiviral therapy plus vitrectomy achieved the lowest RD rate to 18%. Although the efficacy of prophylactic laser or intravitreal antiviral therapy was still limited. Prophylactic vitrectomy might significantly increase the incidence of proliferative vitreoretinopathy from 7% to 32%. CONCLUSION About half of the eyes might develop RD during the entire course of ARN. Systemic antiviral therapy and prophylactic vitrectomy are effective interventions to prevent RD, whereas the roles of prophylactic laser or adjunctive intravitreal antiviral therapy are still unclear. Varicella-zoster virus ARN and cases with extensive retinitis might need intensified interventions.
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Sugita S, Takase H, Nakano S. Practical use of multiplex and broad-range PCR in ophthalmology. Jpn J Ophthalmol 2021; 65:155-168. [PMID: 33420538 DOI: 10.1007/s10384-020-00794-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Polymerase chain reaction (PCR) can be used to confirm or deny infectious ocular inflammation such as uveitis. The purpose of this article is to review the current practical use of PCR examination in ophthalmology, especially multiplex and broad-range PCR, and a novel PCR, termed Strip PCR. At first, in the Introduction, we show the development of the PCR examination in ophthalmology. We next show the clinical applications of multiplex PCR and broad-range PCR. These advances in PCR continue to contribute greatly to the ophthalmology field. We also show how the sample for PCR is collected. Recently, we established a novel examination, a multiplex real-time PCR (Strip PCR) prototype for detecting 24 pathogens responsible for ocular infectious diseases. Moreover, we developed the Direct Strip PCR method, which skips the DNA extraction step in the procedure. This PCR is anticipated to ease etiologic evaluation, increasing pathogen detection in the intraocular fluids of uveitis patients even by general ophthalmologists. We also describe the following: (1) representative cases in which PCR is useful, (2) representative cases in which PCR can exclude a diagnosis, (3) the current status of PCR in the diagnosis of infectious uveitis and advanced medical service, and (4) the prospects for clinical PCR in ophthalmology. CONCLUSION We have established and developed the multiplex PCR, broad-range PCR, Strip PCR, and Direct Strip PCR methods and have reported the efficacy of such tests in multicenter studies. Our goal is "rapid and simple comprehensive PCR diagnosis anywhere and by anyone" for ocular infections.
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Affiliation(s)
- Sunao Sugita
- Department of Ophthalmology, Kobe City Eye Hospital, Kobe, Japan. .,Laboratory for Retinal Regeneration, RIKEN Center for Biosystems Dynamics Research, 2-2-3 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan.
| | - Hiroshi Takase
- Department of Ophthalmology and Visual Science, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoko Nakano
- Department of Ophthalmology, Oita University, Oita, Japan
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14
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Powell B, Wang D, Llop S, Rosen RB. Management Strategies of Acute Retinal Necrosis: Current Perspectives. Clin Ophthalmol 2020; 14:1931-1943. [PMID: 32764860 PMCID: PMC7367936 DOI: 10.2147/opth.s258488] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
Acute retinal necrosis is a rare yet devastating disease, with significant ocular morbidity. Over the past several decades, initial treatment regimens have shifted from intravenous antivirals requiring hospital admission to the routine use of oral antivirals with intravitreal antivirals for immediate local control. Given the rarity of this disease process and a lack of large-scale research trials, debate continues over recommended practice guidelines. In this paper, we review current diagnostic criteria and recommend a treatment algorithm based on available evidence.
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Affiliation(s)
- Brittany Powell
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, United States
| | - Daniel Wang
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, United States
| | - Stephanie Llop
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, United States
| | - Richard B Rosen
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, United States
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15
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Viral Loads in Ocular Fluids of Acute Retinal Necrosis Eyes Infected by Varicella-Zoster Virus Treated with Intravenous Acyclovir Treatment. J Clin Med 2020; 9:jcm9041204. [PMID: 32331430 PMCID: PMC7230916 DOI: 10.3390/jcm9041204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 11/20/2022] Open
Abstract
Acute retinal necrosis (ARN) is a rare viral endophthalmitis, and human herpesvirus is the principal pathogen. Early diagnosis and treatment are critical to avoid visual impairment by ARN, and pars plana vitrectomy (PPV) is required in advanced cases. In this study, we evaluated the transition of viral load in ocular fluids of ARN eyes with varicella-zoster virus (VZV) after intravenous acyclovir treatment. Fourteen eyes of 13 patients were analyzed retrospectively. All patients received intravenous acyclovir treatment, and eventually, all eyes underwent PPV. A polymerase chain reaction (PCR) test showed a 100% detection rate in all aqueous humor samples collected before the treatment (Pre-AH), as well as aqueous humor (Post-AH) and vitreous fluid samples (VF), collected during PPV conducted after the treatment. Within eight days or less of acyclovir treatment, viral loads both in AH and VF did not decrease significantly. Furthermore, the viral load of Pre-AH had a strong correlation with that of VH. These data suggest that in ARN eyes with VZV infection, the AH sample for the PCR test was reliable to confirm the pathogen. We propose that short-term treatment of intravenous acyclovir may be insufficient for reducing intraocular viral load, and the Pre-AH sample could be a predictor of viral activity in the eyes after acyclovir treatment.
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16
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Agarwal M, Gupta C, Jain A, Kumar B. Branch Retinal Artery Occlusion as a presenting sign of Acute Retinal Necrosis: a rare association. J Ophthalmic Inflamm Infect 2020; 10:8. [PMID: 32052206 PMCID: PMC7016156 DOI: 10.1186/s12348-020-0199-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background Acute retinal necrosis (ARN) is a potentially blinding necrotizing viral retinitis. It starts with one or more foci and spreads circumferentially and involves the posterior pole in the later stages. Vascular occlusions such as branch retinal artery occlusion, central retinal artery occlusion, and central retinal vein occlusion may occur secondary to underlying infectious etiology such as ARN. Findings An elderly male patient with a history of coronary artery disease was diagnosed with branch retinal artery occlusion (BRAO) in the right eye and referred to the treating cardiologist. Few days later, he complained of diminution of vision in the left eye which made him seek another consultation when he was diagnosed to have ARN in the left eye, encroaching the posterior pole. He was investigated and treated for the same leading to minimal improvement of vision in the left eye possibly due to a delay in the starting of the anti-viral therapy. Conclusion We report this case to highlight that occlusive vasculopathy can be a presenting sign of an underlying infectious etiology in any age group. BRAO was a rare presenting sign of ARN in our patient. A thorough peripheral examination is recommended in order to avoid missing infectious pathologies such as ARN which starts from the retinal periphery, progresses fast, and if not managed on time may lead to permanent loss of vision.
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Affiliation(s)
- Manisha Agarwal
- Vitreo-retina Department, Dr Shroff's Charity Eye Hospital, 5072, Kedarnath Road, Daryaganj, New Delhi, 110002, India.
| | - Chanda Gupta
- Vitreo-retina Department, Dr Shroff's Charity Eye Hospital, 5072, Kedarnath Road, Daryaganj, New Delhi, 110002, India
| | - Abhishek Jain
- Vitreo-retina Department, Dr Shroff's Charity Eye Hospital, 5072, Kedarnath Road, Daryaganj, New Delhi, 110002, India
| | - Brajesh Kumar
- Vitreo-retina Department, Dr Shroff's Charity Eye Hospital, 5072, Kedarnath Road, Daryaganj, New Delhi, 110002, India
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17
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Jo YJ, Choi SK, Park SH, Lee JJ, Lee JE, Park SW. Retinal Toxicity Following the Injection Ganciclovir into Silicone Oil-filled Eye to Treat Acute Retinal Necrosis. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.1.111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Yeon Ji Jo
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Seung Kwon Choi
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Sun Ho Park
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Jae Jung Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Ji Eun Lee
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
| | - Sung Who Park
- Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea
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18
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Wang D, Bloomberg JD, Sobrin L, Goldstein D, Skondra D. Atypical herpes simplex virus type 2 acute retinal necrosis presentation with large subretinal lesion. Am J Ophthalmol Case Rep 2019; 15:100501. [PMID: 31304428 PMCID: PMC6599871 DOI: 10.1016/j.ajoc.2019.100501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 06/16/2019] [Accepted: 06/18/2019] [Indexed: 11/06/2022] Open
Abstract
Purpose To report the unique clinical findings of a case of Herpes Simplex Virus Type 2 herpetic retinitis manifesting as a large elevated subretinal lesion. Observations A 26-year-old Hispanic male with no significant past medical history presented with a one-week history of right eye pain and endorsement of worsening vision. Ophthalmic examination of the right eye identified a markedly elevated white subretinal lesion with associated findings of vitritis and hypotony. Ultrasound biomicroscopy demonstrated a diffusely thickened choroid and confirmed the observed subretinal mass. Examination of the fellow left eye was largely unremarkable with the exception of lesions suggestive of inactive chorioretinal scars. Diagnostic vitrectomy and vitreous PCR (polymerase chain reaction) was positive only for HSV-2 (herpes simplex virus type 2) and verified by two independent laboratories. The observed subretinal lesion of right eye improved on intravenous acyclovir and intravitreal foscarnet treatment. Conclusions and Importance Presented here is an unusual, novel clinical presentation of HSV-2 acute retinal necrosis manifesting as an elevated subretinal lesion along with findings of panuveitis. This case suggests that consideration should be given to the diagnosis of HSV ARN (acute retinal necrosis) when a subretinal elevation is concomitantly appreciated in the setting of vitritis and chorioretinal lesions.
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Affiliation(s)
- Daniel Wang
- Department of Ophthalmology, New York Eye and Ear Infirmary, 310 E. 14th Street, New York, NY, USA
| | - Justin D Bloomberg
- Department of Ophthalmology, John H Stroger Jr. Hospital of Cook County, 1969 Ogden Avenue, Chicago, IL, USA
| | - Lucia Sobrin
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA, USA
| | - Debra Goldstein
- Department of Ophthalmology, Northwestern University, 645 N. Michigan Avenue, Chicago, IL, USA
| | - Dimitra Skondra
- Department of Ophthalmology, The University of Chicago, 5841 S. Maryland Avenue, Chicago, IL, USA
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19
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Wu XN, Lightman S, Tomkins‐Netzer O. Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review. Clin Exp Ophthalmol 2019; 47:381-395. [DOI: 10.1111/ceo.13500] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 02/08/2019] [Accepted: 02/18/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Xia Ni Wu
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Sue Lightman
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
| | - Oren Tomkins‐Netzer
- Ophthalmology, Moorfields Eye Hospital London UK
- Faculty of Brain Sciences, Institute of Ophthalmology London UK
- Department of OphthalmologyBnai Zion Medical Centre Haifa Israel
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20
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Dave VP, Pappuru RR, Pathengay A, Tyagi M, Narayanan R, Jalali S. Vitrectomy with Silicone Oil Tamponade in Rhegmatogenous Retinal Detachment following Acute Retinal Necrosis: Clinical Outcomes and Prognostic Factors. Semin Ophthalmol 2018; 34:47-51. [DOI: 10.1080/08820538.2018.1551907] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Vivek Pravin Dave
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
| | - Rajeev R. Pappuru
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
| | - Avinash Pathengay
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
| | - Mudit Tyagi
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
| | - Raja Narayanan
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
| | - Subhadra Jalali
- Smt. Kanuri Santhamma Center for Vitreoretinal diseases, LV Prasad Eye Institute, Hyderabad, India
- Retina and Vitreous Service, LV Prasad Eye Institute, Visakhapatnam, India
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21
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Gupta R, Tyagi M, Balakrishnan D, Rani PK. Acute retinal necrosis (ARN) following chickenpox in a patient of Vogt-Koyanagi-Harada (VKH) syndrome using immunosuppressants. BMJ Case Rep 2018; 11:11/1/e227290. [PMID: 30567136 DOI: 10.1136/bcr-2018-227290] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old woman presented with diminution of vision and floaters in both the eyes. Both eyes had disc oedema, multiple pockets of neurosensory detachments along with vitritis. Fluorescein angiography and optical coherence tomography showed characteristic features of Vogt-Koyanagi-Harada (VKH) syndrome (figure 1). She was started on corticosteroid pulse therapy and immunosuppressants following which her VKH lesions resolved. However, she developed chickenpox after 2 weeks and after 1 month she developed discrete yellowish white retinitis patches in the periphery of the right eye which were consistent with a diagnosis of acute retinal necrosis. She was started on oral antivirals for the same and immunosuppressants were withheld in view of immunocompromised state potentially acting as a trigger for reactivation of latent virus. Retinitis patches started to resolve and showed a favourable response to the treatment.
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Affiliation(s)
- Rajan Gupta
- Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases, LV Prasad Eye Institute, Hyderabad, India
| | - Mudit Tyagi
- Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases, LV Prasad Eye Institute, Hyderabad, India
| | - Divya Balakrishnan
- Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases, LV Prasad Eye Institute, Hyderabad, India
| | - Padmaja Kumari Rani
- Smt. Kanuri Santhamma Centre for Vitreo Retinal Diseases, LV Prasad Eye Institute, Hyderabad, India
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22
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Dorman A, Donaldson M. Acute Retinal Necrosis Multicenter Case Series: Prognostic Indicators and Treatment Outcomes. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/2474126418798559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: The purpose of this article is to report the prognostic associations of acute retinal necrosis (ARN), determine the diagnostic utility of aqueous vs vitreous polymerase chain reaction (PCR), and describe outcomes of antiviral, corticosteroid, antithrombotic, and laser retinopexy treatment. Methods: A retrospective, nonrandomized case series was conducted. Primary outcomes included final visual acuity (VA), severe VA loss (≥1.00 log of the minimum angle of resolution [logMAR] [Snellen equivalent, <20/200]), and retinal detachment (RD). Results: Fifty eyes of 46 patients were diagnosed with ARN. Varicella-zoster and herpes simplex viruses were the viral etiology in 29 and 16 eyes, respectively. Five were diagnosed on clinical criteria. Intravenous acyclovir was administered in 90% of eyes. Neither induction therapy for ≥13 days ( P = .692) nor intravitreal medication ( P = .203) decreased the incidence of severe vision loss. Maintenance antiviral medication was administered in 96% of eyes (50% received >13 weeks). At final follow-up, 40% of eyes had severe vision loss (range, –0.08 to +3.0 logMAR [Snellen, 20/17-no perception of light]). Forty-six percent developed RD. Relative afferent pupillary defect (RAPD), zone and extent of retinitis, and RD were prognostic of final VA. Antithrombotic therapy was administered in 25/50 eyes and was associated with lower incidence of severe VA loss ( P = .027) and better final VA ( P = .040). Laser retinopexy was performed in 40% of eyes with no significant effect on RD incidence ( P = .901) or severe VA loss ( P = .451). Conclusions: ARN has a high incidence of RD and poor visual outcomes. Aqueous humor PCR is the first-line diagnostic investigation. Prognostic indicators include RD, RAPD, zone, and extent of retinitis. Induction antiviral medication is appropriate for at least 12 days. Antithrombotic medication is associated with improved outcomes. Laser retinopexy does not reduce the incidence of RD.
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Affiliation(s)
- Andrew Dorman
- Princess Alexandra Hospital, Brisbane, Australia
- Royal Brisbane and Women’s Hospital, Australia
- Gold Coast University Hospital, Australia
- University of Sydney, Australia
| | - Mark Donaldson
- Princess Alexandra Hospital, Brisbane, Australia
- University of Queensland, Australia
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23
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Pirvulescu RA, Popa CA, Romanitan MO, Obretin D, Iancu R, Vasile D. Necrotizing retinitis of multifactorial etiology. Rom J Ophthalmol 2018; 61:49-53. [PMID: 29450371 PMCID: PMC5710053 DOI: 10.22336/rjo.2017.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. We present the case of a 73-year-old woman with osteoporosis, who presented to the emergency room with a sudden vision loss and ocular pain in the right eye, which appeared two days before. The patient mentioned loss of appetite, weight loss for three months and low fever for two weeks. Materials and methods. Among the ophthalmological findings, the most important were panuveitis, and large confluent necrotic areas in the peripheral retina. The patient was diagnosed with RE Panuveitis and acute necrotizing retinitis. Results. Blood exams showed leukocytosis and monocytosis, thrombocytosis and anemia. Further investigations showed high levels of Cytomegalovirus (CMV) anti IgG and Herpes Simplex (HS) type 1 virus anti IgM, urinary infection, and secondary hepatic cytolysis. The CT and MRI of the thorax and abdomen showed no sign of neoplastic disease, and no explanation for the CMV infection was found. The patient received general corticotherapy and antiviral therapy, and, after one month, RE BCVA was 20/ 30. Particularity of the case. Acute necrotizing retinitis in an old patient with CMV and HSV type 1, associated with secondary hepatic cytolysis, without any other immunosuppressive disease and very good outcome.
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Affiliation(s)
- Ruxandra Angela Pirvulescu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ophthalmology Clinic, University Emergency Hospital, Bucharest, Romania
| | - Cherecheanu Alina Popa
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ophthalmology Clinic, University Emergency Hospital, Bucharest, Romania
| | - Mihaela Oana Romanitan
- Department for Clinical Research, Karolinska Institute, Sodersjukhuset, Stockholm, Sweden
| | - Dana Obretin
- Infectious Diseases Department, "Dr. Victor Babes" Clinical Hospital ", Bucharest, Romania
| | - Raluca Iancu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ophthalmology Clinic, University Emergency Hospital, Bucharest, Romania
| | - Danut Vasile
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Surgery 1 Clinic, University Emergency Hospital, Bucharest, Romania
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24
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Comparing Treatment of Acute Retinal Necrosis With Either Oral Valacyclovir or Intravenous Acyclovir. Am J Ophthalmol 2018; 188:173-180. [PMID: 29447915 DOI: 10.1016/j.ajo.2018.02.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 02/01/2018] [Accepted: 02/03/2018] [Indexed: 11/21/2022]
Abstract
PURPOSE To compare the visual outcomes of patients with acute retinal necrosis (ARN) treated initially with intravenous acyclovir vs oral valacyclovir therapy. DESIGN Retrospective, comparative, interventional case series. METHODS Sixty-two patients (68 eyes) with ARN, treated at Moorfields Eye Hospital (United Kingdom) between 1992 and 2016, were identified through the hospital's electronic database. Exclusion criteria included insufficient patient records or follow-up (<150 days). Fifty-six patients had unilateral ARN, while 6 had bilateral ARN. Patients who received intravenous acyclovir on diagnosis (n = 33) were compared with patients treated with oral valacyclovir (n = 29) across outcomes including best-corrected visual acuity, retinal detachment, severe vision loss, and other complications. The impact of adjunctive intravitreal antiviral and prophylactic barrier laser treatment was also assessed. RESULTS Change in best-corrected visual acuity was not significantly different for eyes treated initially with intravenous therapy vs oral therapy over 5 years of follow-up data (P = .16). There was no difference in the rates of severe vision loss between the 2 groups (46% and 59%, respectively, P = .18), or of those eyes retaining good vision (28% vs 31%, respectively, P = .80). Retinal detachment occurred in 63% of cases and did not differ across treatment groups (62% vs 66%, respectively, P = .67). Barrier laser and intravitreal therapy had no effect on retinal detachment rate in either group. CONCLUSION Oral valacyclovir is clinically equivalent to intravenous therapy in the management of ARN. Oral valacyclovir as an outpatient therapy-with or without intravitreal foscarnet-can therefore be considered as an acceptable alternative to inpatient therapy required for intravenous treatment.
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25
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Wong RW, Jumper JM, McDonald HR, Johnson RN, Fu A, Lujan BJ, Cunningham ET. Emerging concepts in the management of acute retinal necrosis. Postgrad Med J 2018; 89:478-85. [PMID: 23861500 DOI: 10.1136/postgradmedj-2012-301983rep] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.
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26
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Shah SP, Hadid OH, Graham EM, Stanford MR. Acute Retinal Necrosis Presenting as Central Retinal Artery Occlusion with Cilioretinal Sparing. Eur J Ophthalmol 2018; 15:287-8. [PMID: 15812776 DOI: 10.1177/112067210501500220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose To report a case of acute retinal necrosis presenting as central retinal artery occlusion with cilioretinal sparing. Methods Single inter ventional case report. The findings of the ophthalmic examination, MRI, blood parameters, biopsy results and clinical course are reported. Results A forty two year old gentleman reporting sudden loss of sight, ophthalmic examination revealing uveitis, central retinal artery occlusion with cilioretinal sparing and peripheral necrotizing retinitis. Conclusions Central retinal artery occlusion can be an early feature of acute retinal necrosis (ARN).
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Affiliation(s)
- S P Shah
- Medical Eye Unit, St Thomas' Hospital, London--UK.
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27
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Bauer D, Keller J, Alt M, Schubert A, Aufderhorst UW, Palapys V, Kasper M, Heilingloh CS, Dittmer U, Laffer B, Eis-Hübinger AM, Verjans GM, Heiligenhaus A, Roggendorf M, Krawczyk A. Antibody-based immunotherapy of aciclovir resistant ocular herpes simplex virus infections. Virology 2017; 512:194-200. [DOI: 10.1016/j.virol.2017.09.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/20/2017] [Accepted: 09/22/2017] [Indexed: 11/29/2022]
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28
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Yanai R, Harada D, Uchi SH, Yamashiro C, Orita T, Sonoda KH, Kimura K. Poor prognosis of elderly individuals >80 years of age with acute retinal necrosis. Am J Ophthalmol Case Rep 2017; 7:107-112. [DOI: 10.1016/j.ajoc.2017.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/16/2017] [Accepted: 06/20/2017] [Indexed: 11/25/2022] Open
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29
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Lee JH, Agarwal A, Mahendradas P, Lee CS, Gupta V, Pavesio CE, Agrawal R. Viral posterior uveitis. Surv Ophthalmol 2017; 62:404-445. [PMID: 28012878 PMCID: PMC5654632 DOI: 10.1016/j.survophthal.2016.12.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 12/12/2016] [Accepted: 12/13/2016] [Indexed: 12/28/2022]
Abstract
The causes of posterior uveitis can be divided into infectious, autoimmune, or masquerade syndromes. Viral infections, a significant cause of sight-threatening ocular diseases in the posterior segment, include human herpesviruses, measles, rubella, and arboviruses such as dengue, West Nile, and chikungunya virus. Viral posterior uveitis may occur as an isolated ocular disease in congenital or acquired infections or as part of a systemic viral illness. Many viruses remain latent in the infected host with a risk of reactivation that depends on various factors, including virulence and host immunity, age, and comorbidities. Although some viral illnesses are self-limiting and have a good visual prognosis, others, such as cytomegalovirus retinitis or acute retinal necrosis, may result in serious complications and profound vision loss. Since some of these infections may respond well to antiviral therapy, it is important to work up all cases of posterior uveitis to rule out an infectious etiology. We review the clinical features, diagnostic tools, treatment regimens, and long-term outcomes for each of these viral posterior uveitides.
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Affiliation(s)
- Joanne H Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Aniruddha Agarwal
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Cecilia S Lee
- Department of Uveitis, University of Washington, Seattle, Washington, USA
| | - Vishali Gupta
- Department of Vitreoretina and Uveitis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Carlos E Pavesio
- Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - Rupesh Agrawal
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Medical Retina, Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom; Department of Ophthalmology, National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore, Singapore.
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Butler NJ, Moradi A, Salek SS, Burkholder BM, Leung TG, Dunn JP, Thorne JE. Acute Retinal Necrosis: Presenting Characteristics and Clinical Outcomes in a Cohort of Polymerase Chain Reaction-Positive Patients. Am J Ophthalmol 2017; 179:179-189. [PMID: 28501392 DOI: 10.1016/j.ajo.2017.05.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 04/28/2017] [Accepted: 05/03/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE To identify determinants of adverse outcomes in acute retinal necrosis (ARN), presenting characteristics and incidence rates of vision loss and ocular complications in a cohort of polymerase chain reaction (PCR)-positive eyes were analyzed. DESIGN Retrospective observational cohort study. METHODS Forty-one eyes of 36 patients with clinically diagnosed ARN, PCR-positive for herpes simplex virus or varicella zoster virus and evaluated between January 2002 and June 2013, were included. Main outcome measures included incidence rates of vision loss and retinal detachment (RD). RESULTS Presenting visual acuity was generally poor (20/50 to >20/200 in 27%; 20/200 or worse in 56%). The incidence rate of ≤20/200 was 0.66/eye-year (EY), (95% confidence interval [CI], 0.32/EY to 1.22/EY); the rate of light perception or no light perception vision was 0.07/EY (95% CI, 0.02/EY to 0.16/EY). During follow-up, 59% of eyes developed at least 1 RD (rate = 0.40/EY, 95% CI, 0.19/EY to 0.58/EY). Eyes with retinitis involving ≥25% of the retina at presentation detached at nearly 12 times the rate, as compared to those with <25% retinal involvement (0.70/EY vs 0.06/EY; P = .001). Development of an RD was the greatest determinant of adverse visual outcomes, with 4% of eyes, that had experienced at least 1 RD, achieving a best-corrected visual acuity of ≥20/40 compared to 53% of eyes that never detached (P = .0003). CONCLUSIONS Poor outcomes in ARN were common in this cohort. RD confers the greatest risk of incident vision loss, and once 25% or more of the retina is involved the risk of RD and visual loss increases significantly.
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Affiliation(s)
- Nicholas J Butler
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.
| | - Ahmadreza Moradi
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sherveen S Salek
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bryn M Burkholder
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Theresa G Leung
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James P Dunn
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer E Thorne
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Şimşek M, Çakar Özdal P, Tekin K. Efficacy of Oral Valacyclovir Treatment in a Case with Acute Retinal Necrosis. Turk J Ophthalmol 2017. [PMID: 28630795 PMCID: PMC5468533 DOI: 10.4274/tjo.14890] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Acute retinal necrosis (ARN) is a rapidly progressive disease with poor prognosis, leading to visual loss in most cases. Rapid diagnosis and early anti-viral treatment significantly affect the course and prognosis of the disease. In this case report, we present a 34-year-old female patient referred to our clinic with symptoms of blurred vision and ocular pain diagnosed as acute glaucoma elsewhere. A clinical diagnosis of ARN was made and anti-viral treatment was started immediately. We herein describe our treatment approach to this particular case and discuss previously reported treatment modalities.
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Affiliation(s)
- Mert Şimşek
- Ulucanlar Eye Training and Research Hospital, Ophthalmology Clinic, Ankara, Turkey
| | - Pınar Çakar Özdal
- Ulucanlar Eye Training and Research Hospital, Ophthalmology Clinic, Ankara, Turkey
| | - Kemal Tekin
- Ulucanlar Eye Training and Research Hospital, Ophthalmology Clinic, Ankara, Turkey
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Drancourt M. Infectious Retinitis and Uveitis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Choi SI, Kim JR, Ra H. Necrotizing herpetic retinopathy in an immune-compromised pediatric patient with minimal signs of inflammation: case report. BMC Ophthalmol 2016; 16:85. [PMID: 27277425 PMCID: PMC4898446 DOI: 10.1186/s12886-016-0253-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 05/21/2016] [Indexed: 02/05/2023] Open
Abstract
Background To report a case of necrotizing herpetic retinopathy(NHR) in an immuno-compromised pediatric patient. Case presentation An 11-year-old boy presented with a minimal ocular foreign-body sensation and peripheral visual-field defect, as well as mild upper respiratory symptoms. He had undergone the Fontan operation for a ventricular septal defect and single ventricle during infancy, and had been taking oral steroids for 1 year immediately prior to his presentation to treat protein-losing enteropathy. Initially, a case of either cytomegalovirus (CMV) retinitis or acute retinal necrosis (ARN) was suspected, and an intravenous course of ganciclovir and acyclovir was therefore initiated. During treatment, varicella-zoster virus (VZV) was detected in the anterior chamber, and ARN was confirmed when both serum and aqueous humor were found by polymerase chain reaction (PCR) to be positive for VZV DNA. A peripheral retinal break and detachment developed after medical treatment, and a vitrectomy was performed. Conclusions Typically, ARN is found in both healthy individuals and subclinically immuno-compromised patients of any age. CMV retinitis is somewhat more typical for immuno-compromised patients. Herein, we report a case of NHR in a pediatric patient with poor general condition and showing minimal signs of inflammation.
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Affiliation(s)
- Soon Il Choi
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, #327 Sosa-ro, Wonmi-gu, Bucheon, 420-717, Korea
| | - Jae Ryun Kim
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, #327 Sosa-ro, Wonmi-gu, Bucheon, 420-717, Korea
| | - Ho Ra
- Department of Ophthalmology and Visual Science, College of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, #327 Sosa-ro, Wonmi-gu, Bucheon, 420-717, Korea.
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Hwang SJ, Kim DR, Kang MH, Seong MC, Cho HY, Shin YU. Treatment of Acute Retinal Necrosis with Acute Kidney Injury after Intravenous Antiviral Injection. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.12.1976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sun Jin Hwang
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Du Roo Kim
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Min Ho Kang
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Min Cheol Seong
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Hee Yoon Cho
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Yong Un Shin
- Department of Ophthalmology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
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Albert K, Masset M, Bonnet S, Willermain F, Caspers L. Long-term follow-up of herpetic non-necrotizing retinopathy with occlusive retinal vasculitis and neovascularization. J Ophthalmic Inflamm Infect 2015; 5:6. [PMID: 25861397 PMCID: PMC4385048 DOI: 10.1186/s12348-015-0038-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 02/07/2015] [Indexed: 11/10/2022] Open
Abstract
Background Herpetic necrotizing retinitis is a well-recognized entity. A few cases of herpetic non-necrotizing retinitis were previously reported. Findings We retrospectively report two cases of herpetic non-necrotizing retinopathy with a long follow-up. A 19-year-old woman presented with a bilateral diffuse occlusive retinal vasculitis, peripheral neovascularization, and no signs of retinal necrosis. Long-lasting immunosuppressive treatment failed to control the vasculitis until herpes simplex virus type 1 (HSV1) was demonstrated by polymerase chain reaction (PCR) in the aqueous. Acyclovir was then added and immunosuppressive tapered and eventually stopped resulting in a resolution of vasculitis. Only two relapses occurred during the next 6 years and responded rapidly to oral acyclovir. An 11-year-old boy presented with unilateral scar of stromal keratitis, severe vitritis, and optic disc neovascularization, followed 6 weeks later by peripheral occlusive retinal vasculitis. Therapeutic and diagnostic vitrectomy was performed, and PCR was found to be positive for varicella zoster virus (VZV) in a vitreous specimen. The inflammation responded to oral acyclovir therapy. Recurrence of anterior uveitis with iris depigmentation occurred 4 months after treatment was arrested. After 4 years, he presented again with a recurrence of anterior inflammation and cystoid macular edema (CME). No sign of inflammation was seen for the next 10 years. Conclusions These rare cases support the possible role of herpes viruses (HSV or VZV) in occlusive vasculitis without retinal necrosis. PCR was useful to raise the diagnosis and to adapt the treatment. A good response was obtained on oral antiviral therapy.
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Affiliation(s)
- Kim Albert
- Department of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre, Rue Haute 322, 1000 Brussels, Belgium ; Centre Hospitalier Universitaire Brugmann, Place Arthur Van Gehuchten 4, 1020 Brussels, Belgium
| | - Maureen Masset
- Department of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre, Rue Haute 322, 1000 Brussels, Belgium ; Centre Hospitalier Universitaire Brugmann, Place Arthur Van Gehuchten 4, 1020 Brussels, Belgium
| | - Sabine Bonnet
- Department of Ophthalmology, Centre Hospitalier Regional de la Citadelle, Boulevard du 12ème de Ligne 1, 4000 Liège, Belgium
| | - François Willermain
- Department of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre, Rue Haute 322, 1000 Brussels, Belgium ; Centre Hospitalier Universitaire Brugmann, Place Arthur Van Gehuchten 4, 1020 Brussels, Belgium
| | - Laure Caspers
- Department of Ophthalmology, Centre Hospitalier Universitaire Saint-Pierre, Rue Haute 322, 1000 Brussels, Belgium ; Centre Hospitalier Universitaire Brugmann, Place Arthur Van Gehuchten 4, 1020 Brussels, Belgium
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Brydak-Godowska J, Borkowski P, Szczepanik S, Moneta-Wielgoś J, Kęcik D. Clinical manifestation of self-limiting acute retinal necrosis. Med Sci Monit 2014; 20:2088-96. [PMID: 25356955 PMCID: PMC4226315 DOI: 10.12659/msm.890469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background The purpose of this paper was to present a case series of self-limiting, peripheral acute retinal necrosis and to demonstrate efficacy of treatment with valacyclovir in patients resistant to acyclovir. The diagnosis was made on ophthalmoscopic examination and positive serum tests for herpes viruses. Material/Methods Ten patients (6F and 4M) aged 19–55 years were diagnosed and treated for self-limiting acute retinal necrosis (ARN). The following endpoints were reported: visual outcomes, clinical features, disease progression, treatment, and complications. Patients received only symptomatic treatment because they did not consent to vitreous puncture. Results Peripheral, mild retinitis was diagnosed in all eyes at baseline. Initially, all patients were treated with systemic acyclovir (800 mg, 5 times a day), prednisone (typically 40–60 mg/day), and aspirin in an outpatient setting. In 6 patients, treatment was discontinued at 6 months due to complete resolution of the inflammatory process. Four patients with immune deficiency showed signs and symptoms of chronic inflammation. Two patients did not respond to acyclovir (2 non-responders); however, those patients were successfully treated with valacyclovir. Complete resolution of inflammatory lesions was observed in 8 patients. In 2 patients, the disease progressed despite treatment – 1 female patient after kidney transplant who stopped the prescribed medications, and 1 male patient with SLE and antiphospholipid syndrome who experienced breakthrough symptoms on-treatment. He died due to cerebral venous sinus thrombosis. Neurological complications (encephalitis and meningitis) were observed in 2 female patients. Prophylactic laser photocoagulation was performed in 1 subject. Conclusions A series of cases of self-limiting acute retinal necrosis (ARN) is presented. This clinical form of ARN can resemble toxoplasmic retinitis in some cases. Oral antiviral medications provide an effective alternative to intravenous formulations in patients with self-limiting ARN. Retinitis is associated with the risk of encephalitis.
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Affiliation(s)
| | - Piotr Borkowski
- Department of Zoonoses and Tropical Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Szymon Szczepanik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | | | - Dariusz Kęcik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
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Affiliation(s)
- Sushmita Kaushik
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Neiwete Lomi
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mini P Singh
- Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder Singh Pandav
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Amod Gupta
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Choudhury H, Jindal A, Mithal K, Bawdekar AC, Pathengay A. Intravitreal triamcinolone acetonide as an adjuvant in the management of acute retinal necrosis. Can J Ophthalmol 2014; 49:279-82. [PMID: 24862775 DOI: 10.1016/j.jcjo.2014.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2013] [Revised: 02/20/2014] [Accepted: 03/16/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To determine the role of intravitreal triamcinolone acetonide (IVTA) as an adjuvant in the management of acute retinal necrosis (ARN). DESIGN Interventional case series. PARTICIPANTS Four eyes of 4 patients diagnosed with ARN were studied. METHODS This pilot case series included 4 patients who presented with clinical features suggestive of ARN. IVTA was injected 1 to 2 weeks after initiation of antiviral therapy and concurrent usage of oral corticosteroids. The disease course and clinical outcome were observed. The patients received additional treatment depending on the sequelae of ARN. RESULTS Signs of reduction in vitritis and resolution of retinitis were observed as early as 1 week after IVTA was administered. In all 4 patients, inflammation promptly resolved with no untoward effects like raised intraocular pressure or worsening of the retinitis. A final visual acuity of 20/40 or better was achieved in 3 of 4 patients after appropriate treatment of ARN-related complications. CONCLUSIONS Intravitreal triamcinolone under antiviral cover could be a useful adjunct to systemic steroids in the treatment of ARN.
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Affiliation(s)
| | - Animesh Jindal
- L V Prasad Eye Institutes, GMRV Campus, Visakhapatnam, India
| | - Kopal Mithal
- L V Prasad Eye Institutes, GMRV Campus, Visakhapatnam, India
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La Cava M, Abbouda A, Restivo L, Zito R. Delayed Onset of Bilateral Acute Retinal Necrosis Syndrome: A 46-Year Interval. Semin Ophthalmol 2013; 30:146-9. [DOI: 10.3109/08820538.2013.833265] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Time profile of viral DNA in aqueous humor samples of patients treated for varicella-zoster virus acute retinal necrosis by use of quantitative real-time PCR. J Clin Microbiol 2013; 51:2160-6. [PMID: 23637296 DOI: 10.1128/jcm.00294-13] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
The objective of this study was to evaluate the kinetics of varicella-zoster virus (VZV) loads using quantitative PCR (qPCR) in patients treated for acute retinal necrosis (ARN). Six patients (52 ± 13 years old) with ARN syndrome were consecutively studied. Aqueous humor (AH) was sampled from both eyes of all patients for qPCR evaluation. The patients were treated with intravenous acyclovir and intravitreal injections of antiviral drugs. The mean follow-up time was 17.6 ± 16.4 months. Main outcome measures were the numbers of viral genome copies in the AH, assessed using real-time qPCR with hydrolysis probe technology with a threshold of detection of 200 copies/ml. Two main portions of the viral load curves were observed for each patient: a plateau phase (27.8 ± 24.9 days) and a decrease in the number of viral genome copies. The mean baseline viral load was 3.4 × 10(7) ± 4.45 × 10(7) copies/ml (6 × 10(6) to 1.2 × 10(8) copies/ml). The viral load decreased according to a logarithmic model, with a 50% reduction obtained in 3 ± 0.7 days. There was a significant viral load (>102 copies/ml) at 50 days after the onset of treatment, despite antiviral drugs. qPCR use demonstrated reproducible VZV DNA kinetics with a two-phase evolution: a plateau followed by a logarithmic decrease. These data suggest that high-dosage antiviral therapy administered for the conventional 10-day duration is insufficient for most patients. This series of patients responded with a similar decrease in viral load once treatment was initiated, and the data from these patients may be used to predict the responses of future patients.
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Virus spread and immune response following anterior chamber inoculation of HSV-1 lacking the Beclin-binding domain (BBD). J Neuroimmunol 2013; 260:82-91. [PMID: 23611643 DOI: 10.1016/j.jneuroim.2013.03.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 03/20/2013] [Accepted: 03/26/2013] [Indexed: 12/15/2022]
Abstract
The autophagy response induced by HSV-1 infection is antagonized by the Beclin-binding domain (BBD). The purpose of this study was to determine if lack of the BBD affects viral spread and immune response in the eyes and brain. Our results showed that lack of the BBD increases autophagy response and activation of NLRP3 inflammasome, which in turn induces a more rapid innate immune response mediated by macrophage/microglia and NK cells in the injected eye, limiting virus replication and retinal damage. We conclude that autophagy plays a role in controlling HSV-1 infection by more rapid induction of the innate immune response.
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Suttorp-Schulten MS, Jager MJ, Kijlstra A. Recent developments in the treatment of posterior uveitis. Ocul Immunol Inflamm 2012; 4:207-17. [PMID: 22827460 DOI: 10.3109/09273949609079654] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Uveitis is an intraocular inflammation that can be caused by infection, autoimmune disease, trauma or malignancy. It is a serious cause of visual handicap and therapy is targeted at: removal of possible infectious agents, the immunological processes that lead to or sustain the inflammation and finally to prevent or treat the destructive effects of the inflammation on the delicate ocular structures. In this review the latest developments concerning the treatment of posterior uveitis are illuminated, e. g., new approaches concerning the treatment of infectious uveitis including the therapy of herpes virus (VZV, HSV and CMV), bacterial and toxoplasma infections of the eye. Several new ways to influence the immune response and inflammation are described including the use of interferons, modulation of cytokines, soft steroids, other new immunosuppressive drugs and treatment of autoimmune uveitis by oral tolerization. An overview is given to illustrate new ways to administer drugs into eyes, such as intravitreal devices. Finally new developments in the field of the treatment of the various complications of uveitis (cystoid macular edema) are described.
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Role of famciclovir in the management of acute retinal necrosis in developing countries. Retin Cases Brief Rep 2012; 6:419-22. [PMID: 25389946 DOI: 10.1097/icb.0b013e31824f7118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate clinical presentations, management strategies, and results in patients with acute retinal necrosis (ARN) who received famciclovir. METHODS In a retrospective, noncomparative, interventional case series, we reviewed case records of patients with ARN from the computerized database between January 2007 and December 2009. Data collected included demographic details of the patient, relevant history, examination findings, drugs administered, clinical response, and final visual acuity. The main outcome measures were visual acuity and clinical response. RESULTS Famciclovir was administered in three cases of ARN. In these three immunocompetent patients, there was complete resolution of ARN with improvement in visual acuity and absence of other eye involvement or recurrence in the primary eye. CONCLUSION One may consider treating ARN with oral famciclovir in immunocompetent patients in developing countries when intravenous acyclovir treatment is not affordable to the patient or when there is clinical resistance to acyclovir.
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Luo YH, Duan XC, Chen BH, Tang LS, Guo XJ. Efficacy and necessity of prophylactic vitrectomy for acute retinal necrosis syndrome. Int J Ophthalmol 2012; 5:482-7. [PMID: 22937510 DOI: 10.3980/j.issn.2222-3959.2012.04.15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 05/31/2012] [Indexed: 11/02/2022] Open
Abstract
AIM To compare the efficacy of prophylactic vitrectomy for acute retinal necrosis syndrome(ARN) with routine treatment in Chinese patients, thereby investigate the necessity of prophylactic vitrectomy for ARN. METHODS Thirty patients (37 eyes) were retrospectively included in this study. The eyes were divided into 2 groups by treatment, including routine treatment, which consisted of antiviral medication and vitrectomy after retinal detachment (RD) (n=21), and prophylactic vitrectomy, which consisted of antiviral medication and vitrectomy for the prevention of RD performed during the active inflammatory phase (n=16). The extent of necrosis was determined by fundus photographs at the time of presentation (for eyes with mild vitreous opacity) or the drawings in the operation records. Necrosis of the 37 eyes was divided into 3 grades, including peripheral, middle-peripheral and extensive. The follow-up period ranged from 8 to 57 months. Differences in visual acuity and necrosis between groups were identified using independent samples t-test. RESULTS Necrosis was more extensive in the routine treatment group than in the prophylactic vitrectomy group (P<0.05). In the routine treatment group, conservative treatment improved necrosis and prevented RD in 6 eyes (29%). Seven eyes (33%) obtained anatomical success, but retinal redetachment occurred in 8 eyes (57%). There were also 5 eyes (24%) developed ocular hypotony or atrophy. Ten eyes (48%) achieved equal or increased visual acuity. In the prophylactic vitrectomy group, RD occurred in 2 eyes (13%). Twelve eyes (75%) were completely anatomically successful, and 10 eyes underwent silicone oil removal. Only one eye (6%) became ocular hypotony. Fourteen eyes (88%) achieved equal or increased visual acuity. The prophylactic vitrectomy group achieved better vision trends than the routine treatment group (P<0.05). Eyes with peripheral necrosis had better visual outcomes than those with mid-peripheral (P<0.05) or extensive (P<0.05) necrosis. However, there was no significant difference between eyes with mid-peripheral and extensive necrosis (P=0.3008) CONCLUSION Prophylactic vitrectomy can prevent RD and improve the prognosis of ARN, making it an option for cases with rapidly progressing necrosis despite antiviral treatment and cases with moderate to extensive necrosis and severe vitreous opacity.
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Affiliation(s)
- Yong-Heng Luo
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Cochrane TF, Silvestri G, McDowell C, Foot B, McAvoy CE. Acute retinal necrosis in the United Kingdom: results of a prospective surveillance study. Eye (Lond) 2012; 26:370-7; quiz 378. [PMID: 22281865 DOI: 10.1038/eye.2011.338] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To determine the incidence of acute retinal necrosis (ARN) in the United Kingdom and to describe the demographics, management, and visual outcome in these patients. METHODS This was a prospective study carried out by the British Ophthalmological Surveillance Unit (BOSU) between September 2007 and October 2008. Initial and 6-month questionnaires were sent to UK ophthalmologists who reported cases of ARN via the monthly BOSU report card system. RESULTS In all, 45 confirmed cases (52 eyes) of ARN were reported in the 14-month study period, giving a minimum incidence of 0.63 cases per million population per year. There were 20 females and 25 males. Age ranged from 10 to 94 years. Eight patients had a history of herpetic CNS disease. Aqueous sampling was carried out in 13 patients, vitreous in 27, and cerebrospinal fluid (CSF) in 4. Varicella-zoster virus followed by herpes simplex were the most common causative agents. Treatment in 76% of the cases was with intravenous antivirals; however, 24% received only oral antivirals. In all, 47% of patients had intravitreal antiviral therapy. Visual outcome at 6 months was <6/60 in 48% of the affected eyes. CONCLUSION The minimum incidence of ARN in the UK is 0.63 cases per million. Patients with a history of herpetic CNS disease should be warned to immediately report any visual symptoms. There is increased use of oral and intravitreal antivirals in initial treatment.
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Affiliation(s)
- T F Cochrane
- Ophthalmology Department, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
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Witmer MT, Pavan PR, Fouraker BD, Levy-Clarke GA. Acute retinal necrosis associated optic neuropathy. Acta Ophthalmol 2011; 89:599-607. [PMID: 20645925 DOI: 10.1111/j.1755-3768.2010.01911.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute retinal necrosis (ARN) syndrome is characterized by severe intraocular inflammation, occlusive vasculopathy and peripheral retinal necrosis. Vision threatening complications of this syndrome include retinal detachment, macular oedema and ischaemia and optic neuropathy. Optic nerve involvement may be the presenting sign of ARN and this condition should be included in the differential diagnosis of acute papillitis. Several mechanisms may lead to ARN associated optic neuropathy including vasculitis, optic nerve ischaemia and direct optic nerve invasion by the herpes virus. We review optic nerve involvement during ARN and present its incidence, pathogenesis, differential diagnosis and treatment.
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Affiliation(s)
- Matthew T Witmer
- Department of Ophthalmology, College of Medicine, University of South Florida, Tampa, Florida, USA.
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Kishore K, Jain S, Zarbin MA. Intravitreal ganciclovir and dexamethasone as adjunctive therapy in the management of acute retinal necrosis caused by varicella zoster virus. Ophthalmic Surg Lasers Imaging Retina 2011; 42 Online:e87-90. [PMID: 21899249 DOI: 10.3928/15428877-20110901-06] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 08/16/2011] [Indexed: 11/20/2022]
Abstract
A 40-year-old man presented with a visual acuity of 20/400 in his right eye due to acute retinal necrosis involving two inferior quadrants. Diagnostic vitreous tap was positive for varicella zoster virus and he received intravitreal injections of ganciclovir (2 mg/0.1 mL) and dexamethasone (400 mcg/0.1 mL). Oral prednisone was added on day 3 and tapered over 3 months. Lesions showed pigmentation around day 5 and healed by day 9. He developed vitreous hemorrhage 5 months after presentation and was treated with 25-gauge pars plana vitrectomy combined with panretinal photocoagulation. Final follow-up at 7 months showed a visual acuity of 20/30, mild optic atrophy, narrow arteries, healed retinal lesions, and good panretinal photocoagulation. Intravitreal injections of dexamethasone and ganciclovir may have a role as an adjunctive therapy in the management of patients with acute retinal necrosis, particularly those caused by varicella zoster virus.
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Cathcart HM, Zheng M, Covar JJ, Liu Y, Podolsky R, Atherton SS. Interferon-gamma, macrophages, and virus spread after HSV-1 injection. Invest Ophthalmol Vis Sci 2011; 52:3984-93. [PMID: 21345992 DOI: 10.1167/iovs.10-6449] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE After uniocular anterior chamber (AC) injection of HSV-1, the anterior segment of BALB/c mice becomes inflamed and infected; however, virus does not spread from the anterior segment to cause retinitis in the injected eye. The purpose of these studies was to determine whether interferon (IFN-)-γ and Mac-1(+) cells play a role in preventing direct anterior-to-posterior spread of HSV-1 in the injected eye. METHODS One AC of adult female BALB/c mice was injected with HSV-1 (KOS). The location of IFN-α, IFN-β, and IFN-γ in the injected eye was determined by immunofluorescence, and mRNA expression was quantified by qPCR. Injected eyes of IFN-γ knockout or clodronate-treated macrophage-depleted mice were examined to determine whether the absence of IFN-γ or Mac-1(+) macrophages affected the sites or timing of virus spread. RESULTS IFN-α, IFN-β, and IFN-γ were observed in the anterior segment of injected eyes through 72 hours and mRNA levels of IFN-β and IFN-γ were increased in virus-infected eyes 48 to 120 hours after infection. However, the absence of IFN-γ or macrophages did not affect either the sites or the timing of HSV-1 infection in injected eyes. CONCLUSIONS Protection of the retina of the injected eye does not depend on a single cell type or cytokine. In addition, in the eye, as in other sites of the body, there are redundancies in the innate response to virus infection.
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Affiliation(s)
- Heather M Cathcart
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta, Georgia 30912, USA
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