Acute retinal necrosis following contralateral herpes zoster ophthalmicus

Clinical course of von Szily reaction: Case report and comprehensive review of the literature

Purpose

To describe a rare case of von Szily reaction (VSR) accompanied by a comprehensive review of the literature.

Observations

A 57-year-old woman with herpes zoster ophthalmicus (HZO) associated with ipsilateral sectoral scleritis and anterior uveitis (sclerouveitis) subsequently developed contralateral necrotizing retinitis, leading to a diagnosis of VSR. A literature review revealed 10 additional cases of VSR. The full VSR cohort of 11 subjects included six women and five men, had a median age of 39 years (range 21–78 years), and most presented with HZO (n = 7, 63.6%), often associated with either ipsilateral anterior uveitis (n = 5; 45.5%) or keratitis (n = 4; 36.4%). All 11 cases developed necrotizing retinitis in the fellow eye, at a median of six weeks following onset in the sentinel eye. The most frequently implicated agent was varicella zoster virus (VZV; n = 8, 72.7%). A high proportion of the eight patients with VZV-associated VSR were identified as having increased risk of VZV reactivation, including age of 50 years or greater (n = 5, 62.5%), an underlying malignancy (n = 3, 37.5%), and/or use of immunosuppressive medication (n = 2, 25.0%).

Conclusion

This was the first reported case of VSR presenting as HZO-associated with sclerouveitis. A comprehensive literature review revealed that most previously reported cases presented with HZO associated with isolated anterior uveitis and/or keratitis, and that all reported cases of VSR developed necrotizing retinitis in the fellow eye, typically within two months of initial presentation. Patients with VZV-associated VSR often had known risk factors for VZV reactivation.

Herpes zoster keratitis development after acute retinal necrosis

PURPOSE

To report a case of herpes zoster keratitis in a patient undergoing treatment for herpetic acute retinal necrosis.

METHODS

Case report.

RESULTS

A 71 year old male presented with acute retinal necrosis of the left eye due to herpes zoster and was treated with intravitreal foscarnet and oral valcyclovir. He developed a retinal detachment and underwent surgical repair. After four weeks, he developed an ipsilateral herpetic zoster keratitis demonstrated by Rose-Bengal staining that was responsive to topical ganciclovir gel.

CONCLUSIONS

This case report describes the unusual development of herpes zoster keratitis after the development of unilateral acute retinal necrosis (ARN) in a patient on antiviral treatment.

The eye in systemic infection

Bacterial, fungal, viral, and parasitic pathogens all cause systemic infection and can spread to the eye. Dissemination of pathogens via the bloodstream can lead to direct involvement of the eye. Visual loss is common in bacterial or fungal endophthalmitis, and toxoplasmosis is a major cause of ocular morbidity and poor vision after congenital or acquired infection. Some infections cause intraocular damage by indirect mechanisms (eg, HIV-mediated immunosuppression), leading to opportunistic infections such as cytomegalovirus infection, periocular nerve involvement due to leprosy, and hypersensitivity reactions in tuberculosis. Eye symptoms might indicate the outcome of an underlying infection, such as development of retinal ischaemia in severe malaria, which is associated with a poor prognosis. Successful outcome for patients with ocular infection depends on close collaboration between clinicians identifying and treating underlying disease, specialist ophthalmic review, and ophthalmic interventional skills (when needed).