Acute Retinal Necrosis: Presenting Characteristics and Clinical Outcomes in a Cohort of Polymerase Chain Reaction-Positive Patients

Cytomegalovirus chronic retinal necrosis with ganciclovir resistance: a case report

BACKGROUND

Cytomegalovirus (CMV) chronic retinal necrosis (CRN) is a rare viral retinal infection that occurs in mildly immunocompromised people. It shares some features with both acute retinal necrosis and CMV retinitis. It is typically treated with combination intravitreal and systemic ganciclovir. We discuss the management of a case of CMV CRN with ganciclovir resistance.

CASE PRESENTATION

An 80-year-old female presented with one month of blurry vision in the left eye. She was being treated with abatacept, methotrexate, and prednisone for rheumatoid arthritis. Examination revealed anterior chamber and vitreous cell along with peripheral retinal whitening. Fluorescein angiogram showed diffuse retinal non-perfusion. Aqueous fluid PCR testing returned positive for CMV. The retinitis was initially controlled with oral and intravitreal ganciclovir, but then recurred and progressed despite these therapies. Ganciclovir resistance was suspected and the patient was switched to intravitreal foscarnet injections, along with oral letermovir and leflunomide, which lead to resolution of the retinitis. The patient has now continued with letermovir and leflunomide for approximately 2.5 years without reactivation of the retinitis or need for further intravitreal anti-viral injections and with adequate control of her rheumatoid arthritis.

CONCLUSION

The incidence of CMV CRN may increase in the future as the use of non-cytotoxic immunosuppressive therapies that result in relatively mild immunosuppression also increases. Treatment with ganciclovir is effective but frequently leads to resistance, as in our case. In this situation, combination therapy with letermovir and leflunomide, particularly in the setting of rheumatoid arthritis where leflunomide can also have an anti-inflammatory effect, can be considered.

Factors at the initial visit associated with poor visual outcomes in patients with acute retinal necrosis

BACKGROUND/OBJECTIVE

Acute retinal necrosis (ARN) is a vision-threatening disease caused by herpesvirus infection. This study aimed to investigate the visual prognostic factors that could be determined at the initial visit.

SUBJECTS AND METHODS

This retrospective study included 34 patients with ARN. Logistic regression analysis was employed to evaluate the associations between poor final visual outcomes and various factors, including poor initial visual acuity, presence of retinal detachment at the initial visit, posterior extension of necrotizing retinitis, and circumferential extension of necrotizing retinitis. Posterior extension was evaluated with three zonings, from the periphery (zone 3), mid-periphery (zone 2), and macula (zone 1). Circumferential extension was evaluated according to the degree of necrotizing retinitis lesions using ultra-wide fundus imaging.

RESULTS

The mean logarithm of the minimum angle of resolution was 0.63 ± 0.68 at the initial visit and 0.83 ± 0.65 at 12 months after the initial visit. Seven patients had a retinal detachment. The distribution of posterior extension at the initial visit was 5 in zone 1, 20 in zone 2, and 9 in zone 3. The average of necrotizing retinitis lesion angle was 249 ± 115°. The logistic regression analysis revealed that participants with wide angles of necrotizing retinitis were associated with final poor vision, with an odds ratio of 1.28 per 30° increase (95%CI: 1.00-1.65, p = 0.03).

CONCLUSIONS

Assessment of the widespread circumferential extension of white necrotizing retinal lesions at the initial visit is a crucial risk factor for the visual prognosis in ARN.

Risk factors and prognostic factors associated with retinal detachment and visual outcomes in acute retinal necrosis

OBJECTIVE

To investigate the risk factors and prognostic factors that affect the long-term clinical outcomes of acute retinal necrosis (ARN).

METHODS

A retrospective study of patients with ARN who underwent treatment and completed follow-up in our ophthalmology department from 2011 to 2021 was conducted. The incidence and risk factors of retinal detachment (RD) and prognostic factors affecting long-term clinical outcomes, such as late-onset RD and final vision loss (< 20/200), were analyzed.

RESULTS

Totally 59 ARN patients (65 eyes) with an average follow-up of 48.9 months were enrolled. During the follow-up period, RD occurred in 34 eyes (52.3%). The risk factors for RD included quadrants of involved retinal necrosis (odds ratio [OR], 4.181; 95% confidence interval [CI], 1.950-10.834) and initial intraocular viral load (OR, 1.721; 95% CI, 1.071-3.083). Early intravitreal antiviral treatment (OR, 1.204; 95% CI, 1.040-1.480) was independently associated with a decreased risk of late-onset RD. The factors independently associated with an increased risk of final vision loss were worse initial visual acuity (OR, 3.895; 95% CI, 1.551-13.662) and late-onset RD (OR, 8.043; 95% CI, 1.380-67.216). In addition, we utilized the fluctuating magnitude of viral load to quantify the extent of its reduction in comparison to its original value following the initial intravitreal antiviral injection (IAI). This ratio was strongly related to initial intraocular IL-8 concentration (Spearman correlation coefficient=-0.741, P = 0.000) and moderately related to the initial degree of aqueous flare (Spearman correlation coefficient=-0.508, P = 0.010).

CONCLUSION

RD is a common and severe complication of ARN with multiple risk factors, such as initial retinitis involvement area and initial intraocular viral load. Active local antiviral therapy may reduce the risk of late-onset RD. The antiviral medication should be adjusted according to the inflammatory state. Therefore, timely detection of causative viruses and intensive systemic and local antiviral therapy is crucial for preserving visual function in ARN patients.

Clinical spectrum and possible pathogenesis of progressive outer retinal necrosis

OBJECTIVE

Progressive outer retinal necrosis (PORN) is an alphaherpesvirus-caused panuveitis with devastating consequences for the eye. Our study aims to describe new findings in the clinical spectrum and propose a mechanism for the pathogenesis of PORN.

METHODS

Observational, consecutive case series. Seven eyes from five patients diagnosed with PORN were enrolled. Detailed case histories, ocular examination findings and multimodal images of retina were collected. Optic nerve and brain imaging were obtained by MRI.

RESULTS

All eyes were confirmed human alphaherpesviruses positive in ocular fluid by qPCR. Optic nerve oedema was observed on MRI in all eyes. A relative afferent pupillary defect was recorded in the affected eye for the unilateral cases. Two patients with unilateral involvement had a history of viral encephalitis and focal encephalomalacia found in the temporal lobe on brain MRI. The affected eyes were characterised by sensory retinal necrosis sparing retinal pigment epithelium, starting at the end of the retinal nerve fibre (horizontal raphe or peripheral area of the retina) and progressing rapidly along the nerve fibre. The wall of the retinal artery and vein was destroyed, resulting in blood flow interruption on fluorescein angiography and retinal haemorrhages along the large vessels.

CONCLUSIONS

Combination the neurotropic characteristics of alphaherpesviruses and the signs of PORN, we hypothesised that the reactivated PORN virus originated from the lateral geniculate nucleus, then propagated along the optic nerve and was released at the terminals, causing necrosis of the entire sensory retina rather than just affecting the outer segment.

Focal Posterior Herpetic Retinitis

Despite having 20/20 vision, a 17-year-old Emirati female presented with central visual changes in her left eye. These changes were attributed to a dull foveal reflex with pigmentary alterations. Retinal pigment epithelium (RPE) mottling at the macula level, attenuating the ellipsoid zone, and a hyper-reflective line connecting the RPE to the outer nuclear layer was observed through spectral domain optical coherence tomography (SD-OCT) of the left eye. In the presence of negative results from laboratory evaluations, the patient was started on oral prednisolone. The medication induced an increased reflectivity of the inner layers on SD-OCT, which turned into a full-thickness macular retinitis with vitreous inflammation, causing a visual decrease to 20/80. A vitreous tap confirmed a positive result for HSV-1, and the patient was prescribed oral valacyclovir 3 g. This treatment led to a resolution of the retinitis and a restoration of the patient's vision to 20/25.

Acute retinal necrosis

Acute retinal necrosis (ARN) is a rare, progressive viral uveitis, with the majority of cases caused by herpesviruses. The diagnosis of ARN is often delayed, and most patients will have some degree of permanent visual loss. We report a case of ARN in a previously healthy 32-year-old patient.

Herpes zoster in neuro-ophthalmology: a practical approach

Herpes Zoster (HZ) or shingles is the reactivation of the Varicella Zoster Virus (VZV), usually along a single sensory nerve, but can affect both sensory and motor cranial nerves. Major risk factors for HZ include immunosuppressed status and age older than 60 years. In the United States, the lifetime risk of HZ is approximately 30%. Worldwide, the median incidence of HZ is 4-4.5 per 1000 person-years across the Americas, Eurasia, and Australia. HZ ophthalmicus, occurring in 10-20% of patients, is an ophthalmic emergency characterized by VZV reactivation along the V1 branch of the trigeminal nerve. Approximately half of this patient subgroup will go on to develop ocular manifestations, requiring prompt diagnosis and management. While anterior segment complications are more common, neuro-ophthalmic manifestations are rarer and can also occur outside the context of overt HZ ophthalmicus. Neuro-ophthalmic manifestations include optic neuropathy, acute retinal necrosis or progressive outer retinal necrosis, cranial neuropathy (isolated or multiple), orbitopathy, and CNS manifestations. Although typically a clinical diagnosis, diagnosis may be aided by neuroimaging and laboratory (e.g., PCR and serology) studies. Early antiviral therapy is indicated as soon as a presumptive diagnosis of VZV is made and the role of corticosteroids remains debated. Generally, there is wide variation of prognosis with neuro-ophthalmic involvement. Vaccine-mediated prevention is recommended. In this review, we summarize neuro-ophthalmic manifestations of VZV.

Common Practice Patterns in the Diagnosis and Management of Acute Retinal Necrosis: A Survey Study of Uveitis Specialists

PURPOSE

Due to lack of large randomized clinical trials to determine best practices in treating acute retinal necrosis (ARN), there is not a clear consensus amongst ophthalmologists on how to best manage this potentially blinding condition. The aim of this study is to survey common practice patterns and analyze the factors that affect ophthalmologists' management of ARN.

METHODS

An anonymous survey was distributed to uveitis and retina specialists who are members of the American Uveitis Society (AUS) via email to query practice patterns regarding ARN. The survey included 22 questions with an additional 10 questions based on response. Survey question topics included demographic information, diagnostic testing, antiviral therapy, corticosteroids, and surgical procedures.

RESULTS

67 surveys were included for analysis. Most respondents (87%) always or frequently obtain intraocular aqueous fluid for diagnostic PCR testing. The majority of respondents would administer intravitreal antiviral injections to a unilateral immunocompetent ARN patient (67%), but would be even more likely to do so for a bilateral immunosuppressed ARN patient (87%). Respondents tend to treat ARN with systemic rather than local corticosteroids, with the majority (63%) of respondents initiating corticosteroid treatment 48 hours after treatment. Most respondents (79%) never perform a vitrectomy to manage ARN unless the patient has a retinal detachment or tear. The majority (63%) rarely or never perform prophylactic laser barricade, but may consider laser treatment if there is extensive retinal involvement.

CONCLUSION

Current practice patterns for diagnosis and management of ARN among AUS members generally align with the suggested practices outlined by the American Academy of Ophthalmology.

Surgery for Infectious Retinitis - When Medical Therapy Is Not Sufficient: The Moacyr E. Alvaro Pan-American Lecture 2023

BACKGROUND

Viral retinitis composes a group of infectious ocular diseases with poor prognoses. With the advent of antivirals and HAART, the treatment of these diseases has evolved and ocular outcomes have improved. However, even with prompt medical treatment, a significant number of patients will experience complications that require surgical intervention. While there has been an abundance of research examining the medical treatment of CMV retinitis and acute retinal necrosis, the research examining surgical outcomes of complications such as retinitis-associated retinal detachment is comparatively limited.

METHODS

Literature review.

RESULTS

In this review, we discuss the current literature examining treatment of CMV retinitis and acute retinal necrosis, with a focus on surgical management of complications such as retinal detachment.

CONCLUSIONS

Despite significant improvements in the medical treatment of CMV retinitis and ARN over the last three decades, vision-threatening complications such as retinal detachment are relatively common and require surgical management via PPV, laser photocoagulation, and intraocular gas or silicone oil tamponade.

Diagnostic and therapeutic challenges in acute retinal necrosis; an update

Acute retinal necrosis (ARN) is a rare but severe ophthalmic pathology defined by panuveitis, retinal necrosis, and high rates of retinal detachment. ARN may lead to poor visual outcomes even if promptly diagnosed and treated. ARN may present with a wide spectrum of clinical findings compatible with panuveitis including anterior uveitis, scleritis, vitritis, necrotizing retinitis, occlusive vasculitis, and optic disc edema. The American Uveitis Society introduced clinical criteria in 1994 for the diagnosis of ARN, while more recent criteria have been proposed by the Standardization of Uveitis Nomenclature (SUN) Working Group and the Japanese ARN Study Group. Multimodal imaging is a valuable tool in evaluating patients with ARN, particularly in unusual cases, while utilizing retinal imaging and applying AI algorithms in these areas of clinical research could be highly beneficial. Over the last few years, significant progress has been made in achieving timely diagnosis and treatment. The precise identification of the viral cause in suspected ARN cases has been greatly enhanced by the advancements in PCR techniques and flow cytometry used for intraocular fluids. systemic (intravenous or oral) antivirals with adjunctive intravitreal antiviral therapy are recommended as first-line therapy to reduce disease severity, the risk of vision loss, and retinal detachment incidence. Although aciclovir was the first existing antiviral agent, at present many clinicians prefer high-dose valaciclovir orally or intravenous aciclovir combined with intravitreal foscarnet. Despite significant progress in diagnosing and treating ARN, further research is needed to improve visual outcomes in this challenging clinical condition.

Case of acute retinal necrosis with rapid progression to proliferative vitreoretinopathy: A case report

RATIONALE

Acute retinal necrosis (ARN) was first reported in 1971 by Urayama et al as an acute uveitis accompanied by retinal arteritis and white retinal lesions in the peripheral retina that can progress to a rhegmatogenous retinal detachment (RRD). We have experienced a case of ARN that, unlike the common developmental course to an RRD associated with ARN, progressed to proliferative vitreoretinopathy (PVR) involving the entire retina in 2 days. The purpose of this report is to present our findings in the case of ARN with an atypical rapid time course.

PATIENT CONCERNS

The patient was a 56-year-old woman who was treated for uveitis of unknown origin by her primary care physician. She was referred to our hospital because of a worsening of the fundus findings.

DIAGNOSIS

Fundus examination in our hospital revealed vitreous opacities in the right eye, yellowish-white lesions extending around the retina, and some retinal hemorrhages. Because the retinal changes suggested ARN, we performed a polymerase chain reaction of the anterior atrial fluid and detected varicella-zoster virus. Then, the diagnosis of ARN was confirmed, and treatment was begun. At 1 month and a half after beginning the treatment, focal retinal traction was observed in the right fundus. Two days later, a circumferential PVR and a total retinal detachment were detected.

INTERVENTIONS

We then performed vitrectomy with an encircling buckle and a silicone oil tamponade.

OUTCOMES

Our examination 6 months postoperatively showed that the retina was attached and the BCVA was 20/200.

LESSONS

Our findings of a case of ARN showed that the progression from a local vitreous traction to a full circumferential PVR can develop in 2 days.

Treatment outcomes of PCR-positive acute retinal necrosis

BACKGROUND

Acute retinal necrosis (ARN) is a progressive necrotizing retinitis caused by viral infection. Optimal management strategies have not been established for this detrimental disease. Previous literature published suggests that Varicella-zoster virus (VZV) and Herpes simplex virus-1 (HSV1) are the most common promoters of acute retinal necrosis (ARN).

AIMS

The purpose of our study was to investigate the viral distribution, demographic, and treatment outcomes of ARN.

METHODS

A retrospective chart review evaluated data from PCR-positive ARN patients diagnosed between 2009 and 2018.

RESULTS

Analysis of fourteen eyes from 12 patients found CMV and VZV as the commonest causes of ARN. Patients on 1 g of valacyclovir three times a day (V1T) had worse vision between first and final visits (mean difference of 1.25 ± 0.65, n = 2) compared with patients treated with 2 g of valacyclovir three times a day (V2T), or 900 mg twice a day of valganciclovir (V9B) (mean difference of - 0.067 ± 0.13, n = 6, and 0.067 ± 0.067, n = 6, respectively). Both V1T patients developed retinal detachments (RD). Both CMV patients treated with intravitreal triamcinolone developed ARN, elevated IOP, and one developed multiple RD.

CONCLUSIONS

Our review found increased incidence of CMV-positive ARN. Patients with zone 1 disease had worse initial visual acuity. Moreover, patients had more favorable outcomes with V2T and V9B compared to V1T. CMV-positive patients clinically worsened after intravitreal steroid injections, further underscoring the value of a PCR diagnosis to tailor the patients' treatment plan accordingly.

Antiviral treatment for acute retinal necrosis: A systematic review and meta-analysis

Acute retinal necrosis is a progressive intraocular inflammatory syndrome characterized by diffuse necrotizing retinitis that can lead to a poor visual outcome, mainly from retinal detachment. The antiviral treatment approach for acute retinal necrosis varies as there are no established guidelines. We summarize the outcomes of acute retinal necrosis with available antiviral treatments. Electronic searches were conducted in PubMed/MEDLINE, EMBASE, Scopus, and Google Scholar for interventional and observational studies. Meta-analysis was performed to evaluate the pooled proportion of the predefined selected outcomes. This study was registered in PROSPERO (CRD42022320987). Thirty-four studies with a total of 963 participants and 1,090 eyes were included in the final analysis. The estimated varicella-zoster virus and herpes simplex virus polymerase chain reaction-positive cases were 63% (95% CI: 55-71%) and 35% (95% CI: 28-42%), respectively. The 3 main antiviral treatment approaches identified were oral antivirals alone, intravenous antivirals alone, and a combination of systemic (oral or intravenous) and intravitreal antivirals. The overall pooled estimated proportions of visual acuity improvement, recurrence, and retinal detachment were 37% (95% CI: 27-47%), 14% (95% CI: 8-21%), and 43% (95% CI: 38-50%), respectively. Patients treated with systemic and intravitreal antivirals showed a trend towards better visual outcomes than those treated with systemic antivirals (oral or intravenous) alone, even though this analysis was not statistically significant (test for subgroup differences P = 0.83).

Posterior Herpetic Uveitis: A Comprehensive Review

PURPOSE

To report and illustrate the main clinical presentations of posterior herpetic uveitis.

METHODS

Narrative review.

RESULTS

The ocular manifestations of posterior herpetic uveitis include different clinical presentations. Herpes simplex and varicella zoster can cause acute retinal necrosis, progressive outer retinal necrosis, and non-necrotizing herpetic retinopathies. Cytomegalovirus has been associated with fulminant retinitis with confluent areas of retinal necrosis and retinal hemorrhages, indolent/granular retinitis, and frosted branch angiitis. These diverse clinical presentations are often associated with specific risk factors and different immunological profiles of the host.

CONCLUSIONS

Herpetic viruses can cause posterior uveitis, presenting various clinical findings. Specific ocular manifestations and the immunological status of the host can help to differentiate the various herpetic entities before laboratory tests confirm the diagnosis.

Surgical Outcomes of Acute Retinal Necrosis-Related Retinal Detachment in Polymerase Chain Reaction-Positive Patients: A Single-Center Experience

PURPOSE

To evaluate the clinical features, operative techniques, and surgical outcomes of patients who underwent surgery for acute retinal necrosis (ARN)-related retinal detachment (RD).

DESIGN

Retrospective, longitudinal, consecutive case series.

PARTICIPANTS

Patients with polymerase chain reaction-positive ARN presenting from 2011 to 2021 who underwent vitreoretinal surgery for ARN-related RD at our institution.

METHODS

Univariate, multivariate, and survival analyses were used to determine predictors of anatomic and functional outcomes.

MAIN OUTCOME MEASURES

Single-surgery anatomic success rate, recurrent RD, and visual acuity (VA) at 1 year.

RESULTS

Thirty-four eyes of 34 patients (32.4% women, mean age, 45.1 ± 20.4 years) were included for analysis with a median follow-up of 2.5 years (interquartile range [IQR], 0.8-5.5 years). Presenting VA was 1.1 ± 0.8 logarithm of the minimum angle of resolution (LogMAR) (Snellen ∼20/250). The median time from presentation to RD surgery was 1.7 months (IQR, 0.8-4.1 months), and the mean preoperative VA was 1.6 ± 0.8 LogMAR (Snellen ∼20/800). Small-gauge pars plana vitrectomy (PPV) with or without a scleral buckle (SB) was performed for all eyes with an overall single-surgery success rate of 63.6%, with no statistically significant differences in visual/anatomic outcomes between PPV and PPV/SB cases. Silicone oil was used for tamponade in 33 (97.1%) cases and was removed in 10 (30.3%) with good anatomic and final functional outcomes (Snellen ∼20/80). Independent predictors of recurrent RD included the female sex (hazard ratio, 8.38; 95% confidence interval, 2.03-34.68; P < 0.01) and zone 1 retinitis involvement at presentation (hazard ratio, 10.95; 95% confidence interval, 2.12-56.48; P < 0.01). The mean VA at 1 year (VA_1year) and at the final follow-up both had a Snellen equivalent of 20/640 (P > 0.05 for both compared with preoperative VA, respectively). Eyes that achieved single-surgery success had VA_1year of 20/200 versus hand movements in those with single-surgery failure (P < 0.01). On multivariate linear regression, younger age (P = 0.04) and better presenting VA (P < 0.01) were both associated with better VA_1year.

CONCLUSIONS

Moderate single-surgery anatomic success can be achieved with modern vitreoretinal surgical techniques for ARN-related RD, although visual outcomes remain poor. Further studies investigating interventions for increasing single-surgery success rates, for the inflammatory complications of ARN, and for preventing ARN-related RD are needed.

Clinical and Virological Characteristics and Prognostic Factors in Viral Necrotizing Retinitis

Purpose: Describe the clinical and virological characteristics of viral necrotizing retinitis (VNR) and assess its prognostic factors. Methods: Retrospective study (Pitié Salpêtrière Hospital, Paris) of consecutive VNR patients diagnosed and monitored by qPCR on aqueous humor between 2015 and 2019. All patients received induction therapy with intravenous +/− intravitreal injections (IVI) of antivirals. Results: Forty-one eyes of 37 patients with a mean age of 56 years were included. Involved viruses were VZV (44%), CMV (37%) and HSV2 (19%). Acute retinal necrosis represented 51%, progressive outer retinal necrosis 12% and CMV retinitis 37% of eyes. Forty-six percent of patients were immunocompromised. Median BCVA was 0.7 LogMAR at baseline and 0.8 LogMAR after an average of 14.1 months. VNR bilateralized in 27% of cases after 32 months. Retinal detachment (RD) occurred in 27% of cases after a mean duration of 98 days. Factors associated with a “poor BCVA” at 1 month were: advanced age, low baseline BCVA, high vitritis grade and viral load (VL) at baseline and the “slow responder” status (i.e., VL decrease <50% after 2 weeks of treatment). Factors associated with RD were: advanced age, immunocompetence, low baseline BCVA, high vitritis grade at baseline and use of ≤5 IVIs. Conclusions: Clinical factors including advanced age, immunocompetence, low BCVA and high vitritis grade at baseline were associated with a poor prognosis. New virological factors were predictive of a poor outcome: high baseline VL and the “slow responder” status. Sequential intraocular fluid sampling might help prognosticate the outcomes of VNR.

Interferon Alpha-2a for the Treatment of Cystoid Macular Edema Secondary to Acute Retinal Necrosis

PURPOSE

To report the results of interferon (IFN) α-2a treatment in patients with cystoid macular edema (CME) secondary to acute retinal necrosis (ARN).

METHODS

We reviewed the records of seven patients (eight eyes) who received IFNα-2a for post-ARN CME. The initial dose of IFNα-2a was 3 MIU/day and it could be tapered down to 3 MIU twice a week. Efficacy was assessed by central macular thickness (CMT) on spectral-domain optical coherence tomography and visual acuity.

RESULTS

Age range of seven patients (four men, three women) was 36-74 years. Mean CMT decreased from 477.9 ± 167.5 μm to 367.3 ± 120.5 μm at first week, and vision improved up to five lines in five eyes. CME relapsed after cessation of IFNα-2a in all and improved following reinstitution of treatment. Treatment was discontinued in one patient because of depression. Three patients electively discontinued treatment due to poor tolerability or lack of functional improvement.

CONCLUSION

IFNα-2a is an effective therapeutic option for post-ARN CME, though side effects such as fatigue, elevated liver enzymes, neutropenia, and depression may limit tolerability. Lower initial doses may be a better tolerated.

Acute retinal necrosis. Management and visual outcomes: a case series

Background

The present study reports the functional and anatomical outcomes of eyes with acute retinal necrosis(ARN).

Methods

This is a retrospective case series conducted at a tertiary Eye Hospital from March 2015 to March 2020. Medical records of patients with clinical and laboratorial—Polymerase Chain Reaction (PCR)—diagnosis of ARN were reviewed. To identify factors related to the outcomes of visual acuity(VA) and retinal detachment (RD) over time, Cox proportional hazards regression modeling and survival analyses were used.

Results

Twenty-three eyes of 23 patients (16 male, 7 female) were reviewed. Based on the PCR results, 16 cases (69.6%) had Varicella zoster virus, 3 cases (13%) had Cytomegalovirus, 1 patient (4.3%) had Herpes simplex virus associated ARN, and 1 case (4.3%) had negative PCR. The incident rate for ≥ 2-line VA gain was 0.28/eye-year (EY) (95% CI 0.21 ± 0.26) while the rate of severe vision loss was 0.09/eye-year (95% CI 0.05 ± 0.08). The RD development was observed at a rate of 0.43/eye-year (0.42 ± 0.02), which occurred in 9 eyes with a mean time of 100 days after the initial presentation of ARN. Patients’ age was the only factor associated with 2-line or more gain in VA over time with a hazard ratio of 0.921 (95% CI 0.854–0.993, P = 0.032).

Conclusions

Generally, although being crucial, treatment is not highly effective in improvement of VA and decrease of RD development, as well as vision loss, in patients with ARN. However, treatment prevents fellow eye involvement efficiently. Younger age is associated with better response to treatment and more chance to achieve better VA.

Socioeconomic disadvantage and impact on visual outcomes in patients with viral retinitis and retinal detachment

While socioeconomic disparities impact clinical care and patient outcomes, their impact on the anatomic and visual outcomes of retinal detachment in patients with viral retinitis is unstudied. This case series included 18 eyes in 18 patients from a single academic institution between January 1, 2008 and December 31, 2018. Patient characteristics including age, sex, race, ethnicity, insurance, immunosuppression, viral retinitis, retinal detachment, retinal detachment repair, visual and anatomic outcomes, missed appointments, and Area Deprivation Index [ADI] were collected. The low-ADI group, indicating less socioeconomic disadvantage, was comprised of twelve patients with national ADIs less than 38, and the high-ADI group of six patients with national ADIs greater than 38. High-ADI patients tended to be younger (average age 38.0 versus 51.3; P = 0.06), of female sex (P = 0.03), and had more missed appointments (median 11.0 vs 0; P = 0.002). A similar number of patients in both the high-ADI and low-ADI groups underwent pars plana vitrectomy alone or pars plana vitrectomy with scleral buckle. Visual acuity was similar in the high-ADI group than in the low-ADI group at baseline, but worse at the final follow-up visit (P = 0.004). Post-operative and final visit ocular hypotony were more common in the high-ADI group (P = 0.02). In our series, socioeconomic disadvantage negatively affects the visual outcomes in patients with viral retinitis associated-retinal detachments. These factors should be considered by ophthalmologists when treating these patients.

Rare cause of left eye floaters and blurred vision in an immunocompromised patient: acute retinal necrosis (ARN)

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.

Role of Prophylactic Vitrectomy in Acute Retinal Necrosis in Preventing Rhegmatogenous Retinal Detachment: Systematic Review and Meta-analysis

PURPOSE

To evaluate the effects of prophylactic vitrectomy for rhegmatogenous retinal detachment (RRD) risk and visual outcome in acute retinal necrosis (ARN).

METHODS

A systematic search of online databases was performed for articles published between 1994 June and 2020 March. The main outcomes that were assessed by a fixed effects model were RRD risk and visual outcome during a follow up period.

RESULTS

A total of 7 trials involving 265 eyes (121 prophylactic vitrectomy eyes vs 144 routine antiviral treatment eyes) were analyzed in this study. RRD risk significantly decreased in the prophylactic vitrectomy group compared to the routine antiviral treatment group (P < .001, OR = 0.27, 95% CI: 0.16-0.46, I² = 35.3%). Significantly deteriorated visual outcome was observed in the prophylactic vitrectomy group in comparison with the routine antiviral treatment group (P < .001, WMD = 0.47, 95%CI: 0.26-0.67, I² = 32.2%).

CONCLUSION

This meta-analysis of retrospective cohort studies revealed that prophylactic vitrectomy could reduce the risk of RRD. The silicone oil tamponade and long-term complications may result in deteriorated visual outcome.

Acute Retinal Necrosis: Signs, Treatment, Complications and Outcome

Background: The Acute Retinal Necrosis (ARN) is an inflammatory, rapidly progressive necrotizing retinitis and vasculitis, most frequently caused by Varicella-Zoster-Virus (VZV), followed by Herpes-Simplex-Virus (HSV), Cytomegalovirus (CMV) and Epstein-Barr-Virus (EBV). The diagnosis is based on clinical signs that were first defined by the American Uveitis Society in 1994 that include one or more foci of retinal necrosis, rapid progression without treatment, circumferential progression, occlusive vasculopathy, and inflammatory signs of the vitreous and anterior chamber Methods: In this retrospective analysis, we included 16 eyes of 10 patients, six patients with simultaneous or delayed bilateral affection, treated for ARN. Status of disease, corrected distance visual acuity (CDVA, decimal), intraocular pressure (IOP), pathogen proof, therapy, and complications were evaluated at diagnosis and 3 months later. Results: In nine patients, the pathogen was identified (six VZV, two HSV, one CMV, one EBV). All patients were treated with systemic and intravitreal virustatic agents. In nine eyes with a CDVA of 0.2 ± 0.2 at hospital admission, vitrectomy was performed, and in seven eyes with CDVA of 0.5 ± 0.3, no vitrectomy was performed (p = 0.04). After 3 months, CDVA of the vitrectomized eyes decreased to 0.1 ± 0.1 vs. 0.4 ± 0.3 (p = 0.01) without vitrectomy. CDVA of fellow eyes affected was 0.6 ± 0.2 at initial presentation vs. 0.2 ± 0.2 for eyes affected first and 0.4 ± 0.3 vs. 0.1 ± 0.1 after 3 months. We observed several complications including retinal detachment, recurrence of the disease, and bulbar hypotony. Conclusion: For fellows eyes affected, diagnosis could be confirmed earlier, leading to a more successful treatment. The success of vitrectomy is difficult to evaluate because vitrectomy is most frequently performed just in the advanced stages of the disease. Early treatment with an appropriate approach is essential to avoid loss of vision.

Risk Factors for Retinal Detachment in Acute Retinal Necrosis

PURPOSE

Retinal detachment (RD) is associated with poor visual outcome in patients with acute retinal necrosis (ARN). This research was undertaken to assess risk factors for RD in ARN.

DESIGN

Retrospective cohort study SUBJECTS: Patients diagnosed with ARN at a tertiary referral center from 2010-2020.

METHODS

Chart review was performed for all clinical and surgical encounters. Univariate and multivariate logistic analysis of demographic and clinical variables associated with RD was performed. Survival analysis with Kaplan-Meier estimates were performed to compare time to RD in HSV- and VZV-associated ARN.

MAIN OUTCOME MEASURES

Demographic information, clinical information including visual acuity, intraocular pressure (IOP), intraocular inflammation level, extent of retinitis, incidence and timing of retinal detachment, date of diagnosis, and treatments performed including intravitreal injections of antiviral medications.

RESULTS

Fifty-four eyes of 47 patients who were diagnosed with ARN were included with equal proportions of eyes (27, 50%) with VZV-ARN and HSV-ARN. Subjects with VZV-ARN were on average older, more likely to be male, and more likely to be immunosuppressed compared with subjects with HSV-ARN. Clinical characteristics were similar between eyes with VZV- and HSV-ARN, including initial visual acuity (VA), initial IOP, anterior segment inflammation, clock hours and posterior extent of retinitis. In univariate analysis of clinical and demographic variables associated with development of RD, initial VA (p = 0.0083) and greater clock hours of retinitis (p = 0.009) were significantly associated with RD. These two variables remained significant in multivariate logistic regression; worse VA at presentation had an odds ratio of 2.34 (95% CI: 1.01 - 5.44) (p = 0.042) and greater clock hours of retinitis had an odds ratio of 1.23 (95% CI: 1.02 - 1.47) (p = 0.025). Kaplan Meier survival analysis demonstrated no statistical difference in RD-free survival between HSV- and VZV-ARN.

CONCLUSION

Patients with VZV-ARN were more likely to be older, male, and immunosuppressed compared to HSV-ARN although no clear difference was observed in RD by viral etiology. Poor initial VA and clock-hours of retinitis were significantly associated with RD development and may be relevant for patient counseling and prognosis.

Acute Retinal Necrosis in an Immunocompetent Patient Treated With Intravitreal Ganciclovir

Acute retinal necrosis (ARN) is an inflammatory syndrome of high clinical concern; untreated or misdiagnosed cases may progress to optic neuropathy or retinal detachment, leading to irreversible blindness. ARN affects men and women equally and is often seen in immunocompromised patients but is also known to present in immunocompetent patients. It is usually due to systemic viral infection with secondary vitreoretinal inflammation. Most commonly, the first-line management of ARN is oral or intravenous antiviral therapy. Here, we report the case of an immunocompetent patient presenting with necrotizing retinopathy secondary to ARN. This patient was treated with oral valacyclovir and then intravenous acyclovir with no improvement. However, intravitreal injection of ganciclovir successfully halted the progression of ARN and led to the preservation of vision in the patient.

Macular dual retinitis with Herpes simplex and Cytomegalovirus following periocular corticosteroid in a patient of Pemphigus Vulgaris

BACKGROUND

Cytomegalovirus (CMV) retinitis may occur in non-HIV individuals following systemic immunosuppressive treatment or periocular corticosteroid administration. However, simultaneous multiple viral retinitis is rare in HIV-negative individuals. We report a case of dual viral retinitis in a non-HIV female on systemic immunosuppressive for pemphigus vulgaris who was administered a periocular corticosteroid injection.

METHOD

A 32-year-old female on double immunosuppressive therapy (prednisolone and cyclophosphamide) for pemphigus vulgaris, presented with gradual painless diminution of vision in the right eye for one month. She was initially diagnosed to have possible autoimmune neuroretinitis by the referring ophthalmologist and received a single injection of posterior subtenon triamcinolone acetonide for the same. Her vision however deteriorated further and she received an intravitreal ganciclovir injection with a revised diagnosis of CMV retinitis. Due to suboptimal response she was referred to us. Aqueous Polymerase chain reaction (PCR) revealed dual positivity for CMV and Herpes simplex virus. She was successfully managed with intravitreal ganciclovir injections, systemic acyclovir and tapering of systemic immunosuppressive drugs.

RESULT

The retinitis lesions resolved gradually leaving behind a pale optic disc and foveal atrophy at 12 weeks follow-up.

CONCLUSION

Infective etiology must be ruled out in immunosuppressed patients before considering periocular corticosteroids. Dual viral involvement, although rare, may cause fulminant retinitis in predisposed individuals. High index of suspicion and PCR from ocular fluids should be performed at the earliest in patients with atypical or poorly responding retinitis lesions.

Therapeutic prognostic factors associated with retinal detachment and visual outcomes in acute retinal necrosis

BACKGROUND

Acute retinal necrosis (ARN) is a fulminant necrotizing vaso-occlusive retinitis associated with a high incidence of vision loss. Prognostic factors associated with the treatment of ARN have not been comprehensively identified. This study aimed to determine therapeutic prognostic factors associated with long-term clinical outcomes in eyes with ARN.

METHODS

This retrospective cohort study included patients with ARN who were treated between 2005 and 2019 in two tertiary ophthalmology departments in Seoul, Korea. Multiple logistic regression analysis was performed to investigate prognostic factors associated with late-onset retinal detachment (RD) and vision loss (<20/200).

RESULTS

Sixty-one eyes with ARN with an average follow-up of 63.5 months were included. Surgical intervention of vitrectomy (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.004-0.47) and intraoperative prophylactic laser use (OR, 0.14; 95% CI, 0.02-0.81) were independently associated with a decreased risk of late RD. The factors independently associated with an increased risk of vision loss were worse initial visual acuity (OR, 3.28; 95% CI, 1.50-7.21), zone 1 involvement of necrotic retinitis (OR, 10.84; 95% CI, 1.62-72.41), and late-onset RD (OR, 5.38; 95% CI, 1.92-31.54).

CONCLUSION

Vitrectomy and/or prophylactic intraoperative laser treatment may be effective treatment options in preventing delayed RD associated with an increased risk of vision loss in eyes with ARN.

ACUTE RETINAL NECROSIS: Difference in Outcome by Viral Type and Options for Antiviral Therapy

PURPOSE

To investigate differences in outcomes of acute retinal necrosis with confirmed viral polymerase chain reaction between viral types and highlight different treatment options.

METHODS

The study evaluated 22 eyes in 18 patients of polymerase chain reaction-positive acute retinal necrosis at the University of Pittsburgh Medical Center from 2007 to 2018. Outcome measures included final visual acuity, treatment paradigms, and retinal detachment rate.

RESULTS

Eight eyes were polymerase chain reaction-positive for varicella zoster virus, two eyes for herpes simplex virus Type 1 (HSV-1), and 12 eyes for herpes simplex virus Type 2 (HSV-2). Final Snellen best-corrected visual acuity averaged 20/51 for varicella zoster virus, 20/25 for HSV-1, and 20/814 for HSV-2. Retinal detachment occurred in 2 (25%) of varicella zoster virus eyes and 8 (75%) of HSV-2 eyes. One eye with HSV-1 and three eyes with HSV-2 received cidofovir for treatment of refractory retinitis.

CONCLUSION

Acute retinal necrosis secondary to HSV-2 tended to have persistent active retinitis with a higher rate of retinal detachment despite similar treatment protocols, suggesting that in some cases combination intravenous acyclovir and adjuvant intravitreal foscarnet injections are not sufficient. Despite the risk of renal toxicity, intravenous cidofovir may be a consideration in select patients.

Association of retinal detachment with age 50 years or younger at onset in patients with acute retinal necrosis

BACKGROUND

Due to the guarded prognosis of acute retinal necrosis (ARN), it is relevant to develop a strategy to early categorize those patients in a higher risk of worse outcomes. The purpose of this study is to describe clinical features and predictive factors for retinal detachment (RD) in patients with ARN.

METHODS

Retrospective observational case series of 34 adult patients (38 eyes) with ARN examined between January 2005 and July 2015 in the National Eye Institute (Bethesda, USA), the Department of Ophthalmology, University of Chile (Santiago, Chile), and APEC (CDMX, Mexico).

RESULTS

A total of 16 males and 18 females with a mean age at presentation of 44.5 ± 16.8 years were included. Twenty-seven patients (79.4%) received intravenous acyclovir as first-line treatment, and 7 patients received either oral antiviral (4 patients) or oral plus intravitreal antiviral (3 patients). All subjects were treated with prednisone, with a mean initial dose of 57.7 ± 16.3 mg per day. Seventeen patients (50.0%) developed retinal detachment. An association of retinal detachment with age at onset was observed (p = 0.04), with patients younger than 50 years presenting a higher risk (OR = 14.86, p = 0.0009). Additionally, patients in this higher risk group had more inflammation in both anterior chamber and vitreous (p = 0.04 and 0.03, respectively). No other predictive factor for retinal detachment was found in the present study.

CONCLUSIONS

RD represents an important complication in patients with ARN. Younger patients may be at higher risk of this complication, possibly secondary to the presence of a higher level of inflammation.

Recent Advances in Diagnosis and Treatment of Infectious Uveitis Prevalent in Asia-Pacific Region

ABSTRACT

The role of infections in intraocular inflammation is being increasingly recognized across the world. The Asia-Pacific region, being the single largest and most populous geographical entity on the planet, is home to a wide variety of such infections. Not surprisingly, there has been an explosion in the literature on infectious uveitis emerging from Asia-Pacific countries. In this review, we have covered recent advances in the diagnosis, treatment, and pathogenesis of common forms of infectious uveitis from the Asia-Pacific region. Much of the literature is focussed on the diagnosis of these infections by clinical criteria and laboratory investigations. There has also been an increased emphasis on the application of newer modes of ocular imaging and understanding pathomechanisms of ocular inflammation in these infections. Together this research has significantly improved our understanding of the diagnosis and management of infectious uveitis.

Advances in the Diagnosis and Management of Acute Retinal Necrosis

Acute retinal necrosis (ARN) is a devastating syndrome characterized by panuveitis, retinal necrosis, and a high rate of retinal detachment that may result in poor visual outcomes if not promptly diagnosed and treated. ARN is most commonly caused by viruses with the herpesvirus family. Etiologies include varicella-zoster virus, herpes simplex virus, and cytomegalovirus, and may be promptly diagnosed by polymerase chain reaction testing of aqueous or vitreous fluid. The true incidence of ARN is not known due to its rarity; as a result, clinical treatment is often guided by retrospective case series, case reports, and expert opinion. Standard of care has evolved over time but currently includes a combination of systemic and intravitreal antiviral in conjunction with topical or oral steroids and surgical therapy as needed. Combination therapy may reduce the rate of severe vision loss and increase the rate of visual acuity gain, although further studies are needed in this area. In particular for patients with mild to moderate disease, combination therapy may reduce the rate of retinal detachment. Adjunctive therapies including oral corticosteroid and prophylactic laser barricade are incompletely studied, but corticosteroid in particular, may reduce inflammation, which also is involved in the severe disease pathogenesis observed in ARN. This review discusses the advances in diagnosis and treatment of ARN, including management with combination antiviral medication and surgical interventions.

Outcomes of Combination Systemic and Intravitreal Antiviral Therapy for Acute Retinal Necrosis

PURPOSE

Determine the efficacy of combination intravitreal and systemic antiviral therapy for the treatment of acute retinal necrosis (ARN) and risk factors impacting visual acuity (VA) and retinal detachment (RD) outcomes.

DESIGN

Single-center retrospective case series.

PARTICIPANTS

Patients with an ARN diagnosis based on clinical features and polymerase chain reaction confirmation who were treated at a tertiary referral, university-based academic practice.

METHODS

Patient records were reviewed for demographic information including age and gender. Snellen VA, disease findings including RD outcomes, optic nerve involvement, and treatments were recorded. Incidence rates of major VA and RD outcomes were calculated based on the number of events and exposure times. Cox proportional hazards regression modeling and survival analyses were used to identify factors related to VA and RD outcomes over time.

MAIN OUTCOME MEASURES

Logarithm of the minimal angle of resolution VA, 2-line or more VA gain, severe vision loss (SVL) of 20/200 or worse, RD development, and fellow eye involvement.

RESULTS

Twenty-three eyes of 21 patients (11 male, 10 female) were reviewed. Thirteen patients (62%) had herpes simplex virus and 8 patients (38%) had varicella zoster virus. The event rate for 2-line or more VA gain was 0.49 events/eye-year (95% confidence interval [CI], 0.26-0.86 events/eye-year), whereas the rate of SVL was 0.61 events/eye-year (95% CI, 0.34-1.02 events/eye-year). Retinal detachment development was observed at a rate of 0.59 events/eye-year (95% CI, 0.33-1.00 events/eye-year). Thirteen of 23 eyes (57%) demonstrated RD with a mean time of 120 days after ARN diagnosis. With each additional quadrant of retina involved, a greater risk of RD development over time was observed (hazard ratio, 2.21; 95% CI, 1.12-4.35). Nine percent of eyes progressed with additional quadrantic involvement, despite combination systemic and intravitreal antiviral therapy; however, none of the 19 patients demonstrating unilateral ARN showed fellow-eye involvement after initiation of therapy.

CONCLUSIONS

Combination intravitreal and systemic antiviral therapy for ARN can be effective in improving VA and limiting retinitis progression. Each additional quadrant of retina involved was associated with a 2.2-fold greater risk of RD, which may impact monitoring, timing of intervention, and patient counseling.

Acute retinal necrosis: Clinical manifestation and long-term visual outcomes in a series of polymerase chain reaction-positive patients

PURPOSE

To report the clinical spectrum, viral etiologies, therapeutic interventions, timing of rhegmatogenous retinal detachments (RRD), and visual outcomes in acute retinal necrosis (ARN) syndrome in a series of polymerase chain reaction (PCR)-positive eyes.

METHODS

From January 2010 to January 2017, consecutive patients with the clinical diagnosis of ARN and a positive aqueous viral PCR were included in this observational, retrospective study.

RESULTS

Nineteen eyes found to have a clinical diagnosis of ARN, of which 18 (94.7%) had a positive viral PCR. ARN was unilateral, except in one patient. None of the fellow eyes manifested ARN during follow-up. Varicella-zoster virus (VZV) was detected in 78.0% of ARN eyes. 61.1% of eyes experienced RRD. The median time for the occurrence of RRD was 12 weeks (range: 6-25 weeks) after disease onset. No correlation was found between the etiologic viral agent (VZV vs non-VZV; p = 1.000), extent of retinitis (1-2 quadrant vs 3-4 quadrants; p = 0.326), administration of intravitreal ganciclovir (injected vs not injected; p = 0.332), application of prophylactic laser retinopexy (applied vs not applied; p = 0.326), and subsequent occurrence of RRD.At a 2-year follow-up, visual impairment (VA ⩽ 20/200) and severe visual loss (VA ⩽ light perception) were significantly higher in those complicated by RRD compared to non-RRD eyes (81.8% vs 28.6%; p = 0.047, and 45.4% vs 0.0%; p = 0.004, respectively).

CONCLUSION

Aqueous PCR results are highly consistent with the clinical diagnosis of ARN. Regardless of the method of management, the rate of RRD is high and is associated with a poor visual outcome.

Neurological and Ophthalmological Manifestations of Varicella Zoster Virus

BACKGROUND

Approximately 1 million new cases of herpes zoster (HZ) occur in the United States annually, including 10%-20% with herpes zoster ophthalmicus (HZO). Postherpetic neuralgia, a debilitating pain syndrome occurs in 30% HZ, whereas 50% HZO develop ophthalmic complications. Diplopia from cranial nerve palsy occurs in less than 30% HZO, whereas optic neuropathy is seen in less than 1% HZO. We reviewed recent developments in the diagnosis, treatment, and prevention of HZ as well as neurological and ophthalmological complications of relevance to the neuro-ophthalmologist.

EVIDENCE ACQUISITION

We searched the English language literature on Pubmed and Google scholar for articles relevant to the various sections of this review.

RESULTS

Antiviral treatment should be initiated within 48-72 hours of onset of HZ and HZO to decrease pain and reduce complications. We recommend neuroimaging in all patients with neuro-ophthalmic manifestations such as diplopia and acute vision loss. Diagnostic confirmation using polymerase chain reaction and serology on paired serum and cerebrospinal fluid samples should be obtained in those with neurological signs and symptoms or abnormal imaging. Patients with neurological and/or retinal varicella zoster virus (VZV) infection should be treated promptly with intravenous acyclovir. Patients with isolated optic neuropathy or cranial nerve palsy can be managed with oral antivirals. The prognosis for visual recovery is good for patients with isolated optic neuropathy and excellent for patients with isolated ocular motor cranial nerve palsy.

CONCLUSIONS

HZ produces a spectrum of potentially blinding and life-threatening complications that adversely affect quality of life and increase health care costs. Individuals at risk for HZ, such as the elderly and immunocompromised, should be encouraged to receive the highly effective VZV vaccine to prevent HZ and its complications.

Visual outcome and poor prognostic factors in acute retinal necrosis syndrome

OBJECTIVE

To evaluate the impact of selected clinical parameters on the mid-/long-term visual outcome of patients with acute retinal necrosis (ARN)

DESIGN

A retrospective cohort study

SETTING

Two University Hospitals (Parma, Italy; Lausanne, Switzerland).

PARTICIPANTS

Thirty-nine non-HIV patients (39 eyes) with ARN, as confirmed by polymerase chain reaction on intraocular samples. The following potential predictors were tested using linear regression models: age, sex, etiology, best-corrected visual acuity (BCVA) on admission, delay between ARN symptom onset and treatment initiation, and surgery (performed or not).

MAIN OUTCOME

BCVA at the final follow up

RESULTS

Thirty-nine of 39 non-HIV patients (22 men and 17 women; mean age, 50 years) diagnosed with ARN were enrolled in the study. Etiologies were: varicella-zoster virus in 25 eyes (64%), herpes simplex viruses in the remaining 14 eyes. The average follow-up duration was 19 ± 13 months. All patients had undergone systemic antivirals; surgery was performed in 16 eyes. The mean delay between onset of visual symptoms and antiviral treatment initiation was 15 ± 31 days (range, 1-180 days). The mean BCVA at baseline was 0.83 ± 0.75 logMAR, while the mean final BCVA was 0.75 ± 0.81 logMAR. Both initial BCVA and treatment delay (TD) were significantly correlated with the final BCVA (p < 0.05).

CONCLUSIONS

Initial BCVA and TD seem to be significant predictors of mid-/long-term visual outcome in non-HIV patients affected by ARN.

Concomitant herpetic keratitis and acute retinal necrosis: clinical features and outcomes

BACKGROUND/OBJECTIVES

The aim of this study was to identify risk factors, prognosis, and management in patients with concomitant herpetic keratitis and acute retinal necrosis (ARN).

SUBJECTS/METHODS

In this retrospective observational series, ARN patients in the Greater Vancouver area from 2004 to 2018 were identified through key words, billing codes, and dispensing data from medical records of affiliate researchers and the pharmacy at Vancouver General Hospital.

RESULTS

Twenty-eight patients were diagnosed with ARN during this period. Five of those were also diagnosed with herpetic keratitis. Thus, the incidence of combined keratitis and ARN was 18% of patients with ARN. The two diseases occurred concomitantly in four out of five patients. Mean age at diagnosis was 55 ± 17 years. Of the five patients with both corneal and retinal involvement, three patients were immunocompromised and three had a history of herpetic diseases. Three developed disciform keratitis and two developed stromal immune keratitis. Clinical management and outcomes of these patients did not differ from patients with ARN alone, except for a lower rate of retinal detachment (p = 0.006) and a higher proportion with visual acuity ≥ 20/200 (p = 0.01).

CONCLUSIONS

Keratitis may complicate the clinical picture of one out of five to six patients with ARN. Comprehensive ophthalmic examination, including careful anterior segment exams in patients with ARN and sequential dilated fundus exams in patients with herpetic keratitis, should always be conducted to identify cases of concomitant disease.

Seasonality of Acute Retinal Necrosis

Purpose

To study the seasonal variability in the occurrence of acute retinal necrosis (ARN) in a series of polymerase chain reaction (PCR)-positive patients.

Methods

Consecutive patients clinically diagnosed with ARN and a positive PCR result of aqueous humor during a seven-year period were studied retrospectively. Patients' demographics, causative viral agent(s), and the date of disease onset were extracted from medical records.

Results

Twenty eyes of 20 patients were enrolled; the mean age at presentation was 39.6 ± 14.4 (range, 6–62) years. Nine patients were female. The most common causative agent was varicella-zoster virus in 16 patients (80%), followed by herpes simplex virus in two patients (10%). The disease onset was in winter in 10 patients (50%), and the highest incidence was in February (five patients, 25%). The cumulative occurrence of ARN was significantly higher in the first half of the year (winter and spring) compared to the second half of the year (summer and fall) (P = 0.030). In general, seasons with a high incidence of ARN were preceded by cold seasons.

Conclusion

In our series, we observed seasonal variability in the incidence of ARN, with the highest incidence during winter and spring. However, further epidemiologic studies in different geographical areas are required to elucidate the true seasonal nature of ARN.

Acute Retinal Necrosis: Virological Features Using Quantitative Polymerase Chain Reaction, Therapeutic Management, and Clinical Outcomes

PURPOSE

To evaluate outcomes of patients treated with intensive intravitreal therapy and to describe the evolution of quantitative real-time polymerase chain reaction (qPCR) in patients treated for acute retinal necrosis (ARN) syndrome.

DESIGN

Retrospective observational case series.

METHODS

This study included 25 eyes of 24 patients with ARN who were treated and followed up in 2 departments of ophthalmology in Lyon, France. Assessed outcomes included qPCR viral load profile during treatment, number of antiviral intravitreal injections (IVT), retinal detachment rate, and best-corrected visual acuity.

RESULTS

Final visual acuity was 20/200 or less in 20% of cases; the rate of retinal detachment was 16%. Viral load kinetics changed in 3 phases: a first plateau period that was not consistent, a logarithmic decrease phase, and a negativation phase. Mean decay of the logarithm of the viral load was estimated at 0.076 per day; mean time of negativation was 56.1 days. Median IVT number was 9 (range, 0-28). Ten patients were treated with injections until the viral load was undetectable. Resistance to acyclovir was observed in a patient with a prolonged initial plateau of the viral load.

CONCLUSIONS

Numerous and prolonged IVTs, used as adjunctive therapy, could improve the prognosis of treated patients by decreasing the risk of retinal detachment and improving visual acuity. QPCR enables monitoring of the response to treatment and can provide evidence for resistance to antiviral treatment by enabling the detection of cases with a prolonged initial plateau of viral load.

Risk of Rhegmatogenous Retinal Detachment in Acute Retinal Necrosis With and Without Prophylactic Intervention

PURPOSE

To study whether preventive laser or preventive vitrectomy is able to lower the risk of rhegmatogenous retinal detachment (RRD) in patients with acute retinal necrosis (ARN).

DESIGN

A retrospective, interventional case series.

METHODS

We performed a retrospective study of 59 patients (63 eyes) with ARN treated in a single tertiary referral center. We analyzed different groups with either no prophylaxis, prophylactic laser, or prophylactic vitrectomy. Main outcome measure was incidence of RRD.

RESULTS

Overall incidence of RRD was 44.4%, including 13% at presentation. In a crude analysis, the risk of RRD was highest in 33 patients with prophylactic laser (45.5%), lower in 15 patients with no prophylaxis (26.7%), and lowest in 7 patients with prophylactic vitrectomy (14.3%). Baseline best-corrected visual acuity differed between these groups, but zone and percentage of involved retina did not. In a multivariable model including prophylactic laser and ARN severity, only zone was predictive of RRD.

CONCLUSION

When correcting for severity of disease, we did not observe a reduction in the risk of RRD by prophylactic laser in eyes with ARN. Therefore, prophylactic laser may be abandoned. The role of prophylactic vitrectomy is still unclear, but deserves further investigation.

Fulminant bilateral acute retinal necrosis complicated with secondary herpes simplex type-1 viral encephalitis: A case report

RATIONALE

Acute retinal necrosis (ARN), which is characterized by peripheral necrotizing retinitis, severe retinal arteritis, and progressive inflammatory reaction in the vitreous and anterior chambers, has been reported in cases with herpes simplex encephalitis (HSE). It is a relatively rare complication secondary to HSE. However, cases presented with viral encephalitis following ARN were seldom reported.

PATIENT CONCERNS

A 43-year-old immunocompetent male patient manifested the aforesaid reverse situation. He developed HSE following 3-day systemic steroid therapy for abrupt ocular pain and rapidly decreased visual acuity, which was later diagnosed as ARN. Polymerase chain reaction (PCR) analysis of vitreous specimen verified herpes simplex virus-1 (HSV-1) infection.

DIAGNOSIS

HSE associated with ARN.

INTERVENTIONS

The patient was treated with intravenous acyclovir (500 mg every 8 h) for 21 days. A pulse of intravenous methylprednisolone, 500 mg/d for 5 days was given as an anti-inflammatory therapy, followed by prednisone taper.

OUTCOMES

The patient's neurological symptoms got improved very soon after the therapy, but his vision acuity remained no perception of light in both eyes.

LESSONS

The present case indicates that ARN can also be a risk factor for HSE. Once ARN was suspected, corticosteroid should be applied with caution and in combination with antiviral treatment to avoid progressive duplication of virus and its spread to the brain.

Acute retinal necrosis in a patient with remote severe herpes simplex encephalitis

A 60-year-old man with a history of severe herpes simplex virus type 1 (HSV-1) encephalitis 2 years prior presented with acute onset of visual loss in the left eye. Dilated funduscopic examination showed retinitis and occlusive vasculitis with retinal necrosis. PCR of the vitreous fluid was positive for HSV-1, and he was diagnosed with acute retinal necrosis (ARN) due to HSV-1. The patient was treated with intravenous acyclovir and intravitreous foscarnet for 2 weeks, followed by high dose oral valacyclovir for 2 weeks. He was subsequently placed on planned life-long suppressive valacyclovir. His case demonstrates that acute visual loss concomitant with or subsequent to HSV-1 encephalitis warrants suspicion of ARN. Prompt therapy with effective antiviral medication is necessary to reduce the risk of sight-threatening complications. Chronic suppression with oral antiviral therapy after ARN is recommended to prevent involvement of the contralateral eye, though there is no consensus on the duration and dosage of antivirals.

Acute Retinal Necrosis Multicenter Case Series: Prognostic Indicators and Treatment Outcomes

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.