The acute retinal necrosis syndrome. Part 2: Histopathology and etiology

Long-Term Functional Outcomes of Retinal Detachment Due to Acute Retinal Necrosis: A Case Series

Objectives: To evaluate the long-term anatomical and functional prognosis of patients with retinal detachment (RD) secondary to acute retinal necrosis (ARN) treated with pars plana vitrectomy (PPV). Methods: This retrospective case series included 21 eyes from 21 patients with RD secondary to ARN. The study analyzed vitreous or aqueous biopsy results, the impact of antiviral therapy, time to retinal detachment, changes in visual acuity (VA), and anatomical and surgical outcomes. All cases underwent 23-gauge PPV with silicone oil tamponade, and an episcleral encircling band was used in 11 cases. All patients received systemic antiviral therapy at diagnosis. Results: Retinal reattachment was achieved in 91% of cases during follow-up, with an average follow-up period of 39.5 ± 36.8 months. The average time from ARN diagnosis to RD onset was 33.3 ± 27.5 days. VZV was detected in 10 eyes through PCR analysis. Significant differences in visual prognosis were found between macula-off and macula-on RD (p = 0.048). Eyes with optic nerve head inflammation had worse final VA (p = 0.010). No significant difference was observed between preoperative VA and VA at the end of follow-up (p = 0.665). Conclusions: VZV was the primary virus associated with ARN-related RD. Early involvement of the macula and optic nerve in retinitis negatively impacted the final visual prognosis.

Prognostic factors associated with acute retinal necrosis treated non-surgically

OBJECTIVES

To analyse the prognostic factors for visual acuity in acute retinal necrosis (ARN) patients treated non-surgically.

METHODS

The clinical data of ARN patients who visited our hospital from January 2010 to January 2023 were retrospectively analysed.

RESULTS

Twenty-four patients (29 eyes) were included. Aqueous humour samples were collected from 20 out of 29 eyes, and PCR confirmed that 85% (17/20) of the eyes had VZV infection, 10% (2/20) had CMV infection, and 5% (1/20) had HSV infection. All patients were treated with intravenous antiviral agents. Intravitreal ganciclovir and oral corticosteroids were given according to the patients' wishes. A comparison of visual acuity at the time of first identification of inactive ARN with that at the first visit revealed that 16 (55.2%) eyes improved and 13 (44.8%) did not improve. Logistic regression analysis revealed that risk factors for failure to improve vision after treatment included retinal detachment (odds ratio [OR],33.75; 95% CI, 3.245-351.067; P = 0.003), necrotising retinitis involving the posterior pole (odds ratio [OR],8.167; 95% CI, 1.297-51.403, P = 0.025), and arteritis involving the large retinal arteries (odds ratio [OR],9.167; 95% CI, 1.493-56.297; P = 0.017). The VZV viral load in the aqueous humour at initial presentation was significantly associated with visual prognosis (r = 0.688, P = 0.013), retinal detachment (τ = 0.597, P = 0.021) and the extent of retinal necrosis (τ = 0.57, P = 0.027). The neutrophil to lymphocyte ratio (NLR) of VZV-infected patients at first presentation was significantly correlated with the prognosis of visual acuity (r = 0.616, P = 0.033) and retinal detachment (τ = 0.728, P = 0.004).

CONCLUSIONS

High NLR and viral DNA copy number in the aqueous humour at the initial presentation, as well as subsequent retinal detachment, necrotising retinitis involving the posterior pole, and arteritis involving the large retinal arteries were risk factors for poor visual prognosis in VZV-infected ARN patients.

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.

Choroidal Involvement in a Case of Viral Retinitis

PURPOSE

To describe a challenging case of acute retinal necrosis.

METHODS

Clinical data, including medical history, clinical findings and imaging features were retrospectively collected in a 28-year-old female with unilateral active retinitis.

RESULTS

The yellowish area of retinitis surrounding a pigmented chorioretinal scar and the full thickness retinal hyper-reflectivity associated with diffuse increase in choroidal demonstrated a challenging case of necrotising retinitis, where baseline clinical and tomographic features were atypical and misleading towards a toxoplasmic aetiology. The detection of virus genome in ocular samples was necessary to achieve a correct diagnosis of acute retinal necrosis.

CONCLUSION

Although rare, choroidal involvement may occur in acute retinal necrosis along with the well-known retinal features.

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.

Unusual pattern of herpetic optic neuropathy: a case report and literature review of the pathophysiology of herpetic uveitis

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.

Acute retinal necrosis: pathophysiological aspects, diagnosis, and treatment

Acute retinal necrosis (ARN) is a devastating viral infection commonly associated with varicella zoster virus (VZV) and herpes simplex virus types 1 and 2 (HSV-1, HSV-2). Typically, ARN affects individuals without immune status disorders between the ages of 50-70. In two-thirds of the cases, one-eye involvement is observed and the inflammation can be presented as panuveitis. The most characteristic clinical manifestations are vitreitis, occlusion of the retinal arterioles, and peripheral necrotizing retinitis. Retinitis presents with the appearance of deep, multifocal, yellowish-white foci, typically localized in the peripheral retina. Systemic antivirals are the first treatment of choice for ARN. The goal of the therapy is to stop the viral replication and disease progression in the affected eye, as well as to prevent involvement of the healthy eye. The other eye can be attacked in an interval of 5 days to 30 years. The visual prognosis after illness is poor. Early diagnosis and timely initiation of treatment play an important role in maintaining visual acuity and preventing the other eye from being affected.

Cytopathology of Vitreous Specimens in Acute Retinal Necrosis

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.

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.

Advances in the microbiological diagnosis of herpetic retinitis

Viral retinitis associated with herpesvirus is one of the most severe forms of uveitis and is a potentially sight-threatening ophthalmologic disease. The prognosis is poor and a rapid and aggressive management is necessary to improve the visual and sometimes vital prognosis of these patients. The treatments used are not without side effects, while many differential diagnoses exist, such as toxoplasmic retinochoroiditis, syphilitic retinitis, endogenous endophthalmitis and intraocular lymphoma. Causatives viruses are herpes simplex virus, varicella-zoster virus, and cytomegalovirus, which require rapid detection in ocular fluid, mainly aqueous humor. However, only a small amount of intraocular fluid is available for analysis. Advances in microbiological diagnostic techniques therefore were key factors in improving the management of these diseases. Historically, the diagnosis was based on immunological tests but more recently advances in molecular biology, in particular polymerase chain reaction, have played a crucial role to obtain a reliable and rapid diagnosis of viral retinitis associated with herpesvirus, as discussed in this review.

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.

Classification Criteria for Acute Retinal Necrosis Syndrome

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.

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.

Clinically applicable artificial intelligence algorithm for the diagnosis, evaluation, and monitoring of acute retinal necrosis

The prompt detection and proper evaluation of necrotic retinal region are especially important for the diagnosis and treatment of acute retinal necrosis (ARN). The potential application of artificial intelligence (AI) algorithms in these areas of clinical research has not been reported previously. The present study aims to create a computational algorithm for the automated detection and evaluation of retinal necrosis from retinal fundus photographs. A total of 149 wide-angle fundus photographs from 40 eyes of 32 ARN patients were collected, and the U-Net method was used to construct the AI algorithm. Thereby, a novel algorithm based on deep machine learning in detection and evaluation of retinal necrosis was constructed for the first time. This algorithm had an area under the receiver operating curve of 0.92, with 86% sensitivity and 88% specificity in the detection of retinal necrosis. For the purpose of retinal necrosis evaluation, necrotic areas calculated by the AI algorithm were significantly positively correlated with viral load in aqueous humor samples (R²=0.7444, P<0.0001) and therapeutic response of ARN (R²=0.999, P<0.0001). Therefore, our AI algorithm has a potential application in the clinical aided diagnosis of ARN, evaluation of ARN severity, and treatment response monitoring.

Histopathology and Molecular Biology Study of an Eyeball of a Case of Acute Retinal Necrosis

Purpose: To report a histopathology and molecular biology study of an eyeball of a case of acute retinal necrosis (ARN).Methods: Histopathology, immunohistochemistry and molecular biology of an enucleated globe of acute retinal necrosis 6 years after the onset of ARN.Results: Histopathology showed persistence of chronic inflammatory cells with herpes virus inclusion body. Semi nested polymerase chain reaction showed varicella zoster virus.Conclusions: Chronic inflammatory cells and viral genome can be persistent even after 6 years after the onset of ARN.

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.

Management Strategies of Acute Retinal Necrosis: Current Perspectives

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.

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.

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.

Branch Retinal Artery Occlusion as a presenting sign of Acute Retinal Necrosis: a rare association

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.

Alpha herpes virus type and viral load in intraocular fluids in patients with acute retinal necrosis

Objectives

To identify all patients tested positive for herpes viruses in intraocular samples between 2007 and 2016 in South-Western Sweden and evaluate which of these met the criteria of acute retinal necrosis (ARN). To compare viral load in intraocular samples and virus type with clinical outcome.

Method and analysis

Retrospective case series. Intraocular samples and serum were analysed with quantitative real-time PCR (qPCR) and presence of antibodies (IgG and IgM) were detected by ELISA in serum.

Results

Between 2007 and 2016, 13 patients met the clinical criteria of ARN and were PCR-positive in aqueous or vitreous for herpes simplex virus 1 (HSV1; n=4), herpes simplex virus 2 (HSV2; n=3) and varicella zoster virus (VZV; n=6). None of the patients tested positive for cytomegalovirus (n=13) or Epstein Barr virus (n=2) met the criteria of ARN. All ARN patients had specific serum IgG and three patients exhibited virus DNA in serum. There was no correlation between high viral load and worse visual outcome. However, higher viral loads were seen in samples taken earlier in the disease process. Median age was higher (p=0.049) in VZV-ARN than for HSV-ARN patients (60.5 and 45.4 years, respectively) with a tendency of worse best corrected visual acuity at presentation (1.62 and 0.79 log MAR, respectively; p=0.079).

Conclusion

ARN is a reactivation of alpha herpes virus and presence of herpes DNA in serum may occur. VZV-ARN are older than HSV-ARN patients. High viral load does not appear to be a predictor of worse visual outcome, but rather indicates earlier sampling.

Herpetic Panophthalmitis: A Diagnostic Dilemma

Purpose: To describe an uncommon presentation of ocular infection caused by human herpes simplex virus 2 (HSV-2).Methods: Case report.Results: A 32-year-old female with no prior history of mucocutaneous herpesvirus infection presented with a minimally painful hypertensive granulomatous panophthalmitis and optic neuropathy that was initially suspected to be orbital cellulitis. Her disease progressed despite antibiotic and steroid treatment, and HSV-2 was ultimately identified in the vitreous.Conclusion: Although rare, ocular infection by human herpesvirus can present as a panophthalmitis. The case is discussed in the context of two previously reported cases of herpes simplex panophthalmitis, as well panophthalmitis caused by varicella zoster virus.

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.

Pediatric Uveitis

Pediatric uveitis differs from adult-onset uveitis and is a topic of special interest because of its diagnostic and therapeutic challenges. Children with uveitis are often asymptomatic and the uveitis is often chronic, persistent, recurrent, and resistant to conventional treatment. Anterior uveitis is the most common type of uveitis in children; the prevalence of intermediate, posterior, and panuveitis varies geographically and among ethnic groups. Regarding etiology, most cases of pediatric uveitis are idiopathic but can be due to systemic inflammatory disorders, infections, or a manifestation of masquerade syndrome. Ocular complications include cataracts, hypotony or glaucoma, band keratopathy, synechiae formation, macular edema, optic disc edema, choroidal neovascular membranes, and retinal detachment. These complications are often severe, leading to irreversible structural damage and significant visual disability due to delayed presentation and diagnosis, persistent chronic inflammation from suboptimal treatment, topical and systemic corticosteroid dependence, and delayed initiation of systemic disease‒modifying agents. Treatment for noninfectious uveitis is a stepwise approach starting with corticosteroids. Immunomodulatory therapy should be initiated in cases where quiescence cannot be achieved without steroid dependence. Patients should be monitored regularly for complications of uveitis along with systemic and ocular adverse effects from treatments. The goals are to achieve steroid-free durable remission, to reduce the risk of sight-threatening complications from the uncontrolled ocular inflammation, and to avoid the impact of lifelong burden of visual loss on the child and their family. Multidisciplinary management will ensure holistic care of affected children and improve the support for their families.

Comparing Treatment of Acute Retinal Necrosis With Either Oral Valacyclovir or Intravenous Acyclovir

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.

Emerging concepts in the management of acute retinal necrosis

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.

Acute Retinal Necrosis Presenting as Central Retinal Artery Occlusion with Cilioretinal Sparing

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).

Intraocular Detection of Herpes viruses by xTAG Liquid Chip Technology in Patients with Acute Retinal Necrosis

PURPOSE

To evaluate the performance of the xTAG liquid chip technology (xTAG-LCT) for etiological diagnosis of acute retinal necrosis (ARN).

METHODS

Fifteen vitreous and 3 aqueous samples from 18 ARN patients were analyzed by xTAG-LCT and multiplex PCR (mPCR)/quantitative PCR (qPCR).

RESULTS

xTAG-LCT revealed positive results in 17 of the 18 samples: 10 for Varicella Zoster Virus (VZV) alone; 5 for VZV and Epstein-Barr virus (EBV); 1 for herpes simplex viruses type 1 (HSV-1) and EBV; 1 for VZV, HSV-1 and EBV. While mPCR revealed the same results as xTAG-LCT for VZV and HSV-1 in all samples, only 2 of the 7 samples positive for EBV on xTAG-LCT were confirmed by qPCR. None of the 28 control vitreous samples from 8 non-ARN patients and 10 pair of cadaveric eyes was positive for any of the tested viruses.

CONCLUSIONS

xTAG-LCT could be a useful alternative for etiological diagnosis of ARN.

Concomitant Intravitreal Ganciclovir and Dexamethasone Therapy in the Management of Acute Retinal Necrosis in a Patient Previously Treated with Oral Famciclovir

Several treatments have been reported for acute retinal necrosis (ARN). We report a case of treatment with intravitreal injection of ganciclovir and dexamethasone in addition to oral valacyclovir in a patient who was previously treated with oral famciclovir for ipsilateral herpes zoster ophthalmicus (HZO).

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

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.

Diagnosis and Treatment of Acute Retinal Necrosis: A Report by the American Academy of Ophthalmology

PURPOSE

To evaluate the available evidence in peer-reviewed publications about the diagnosis and treatment of acute retinal necrosis (ARN).

METHODS

Literature searches of the PubMed and Cochrane Library databases were last conducted on July 27, 2016. The searches identified 216 unique citations, and 49 articles of possible clinical relevance were reviewed in full text. Of these 49 articles, 27 were deemed sufficiently relevant or of interest, and they were rated according to strength of evidence. An additional 6 articles were identified from the reference lists of these articles and included. All 33 studies were retrospective.

RESULTS

Polymerase chain reaction (PCR) testing of aqueous or vitreous humor was positive for herpes simplex virus (HSV) or varicella zoster virus (VZV) in 79% to 100% of cases of suspected ARN. Aqueous and vitreous specimens are both sensitive and specific. There is level II and III evidence supporting the use of intravenous and oral antiviral therapy for the treatment of ARN. Data suggest that equivalent plasma drug levels of acyclovir can be achieved after administration of oral valacyclovir or intravenous acyclovir. There is level II and III evidence suggesting that the combination of intravitreal foscarnet and systemic antiviral therapy may have greater therapeutic efficacy than systemic therapy alone. The effectiveness of prophylactic laser or early pars plana vitrectomy (PPV) in preventing retinal detachment (RD) remains unclear.

CONCLUSIONS

Polymerase chain reaction testing of ocular fluid is useful in supporting a clinical diagnosis of ARN, but treatment should not be delayed while awaiting PCR results. Initial oral or intravenous antiviral therapy is effective in treating ARN. The adjunctive use of intravitreal foscarnet may be more effective than systemic therapy alone. The role of prophylactic laser retinopexy or early PPV is unknown at this time.

[Role of oral antiviral therapy in the treatment of acute retinal necrosis]

Le syndrome de nécrose rétinienne aiguë (RNA) est un syndrome uvéitique rare mais dévastateur pour la vue (pronostic visuel ++). Son diagnostic doit être précoce du fait de sa gravité et du risque de bilatéralisation. C’est une entité rare causée par les virus du groupe Herpès. Chez les patients immunodéprimés, les complications de l’ARN syndrome conduisent souvent à une perte d’acuité visuelle. La confirmation de ce diagnostic dès la découverte de la maladie par la réaction de polymérase en chaîne (PCR) et par le coefficient de charge immunitaire (CCI) le plus souvent par ponction d’humeur aqueuse permet d’optimiser la prise en charge en diminuant le temps nécessaire à une confirmation diagnostique. L’ARN syndrome est de très mauvais pronostic spontané. Des études récentes ont montré que la thérapie orale antivirale (valaciclovir, famciclovir et valganciclovir) et intravitréenne sans traitement intraveineux initial est un traitement efficace de l’ARN. Nous présentons ici le tableau clinique d’un jeune patient âgé de 39 ans admis aux urgences pour baisse d’acuité visuelle. L’examen ophtalmologique a objectivé une nécrose rétinienne aigue unilatérale. Il fut traité par une thérapie antivirale orale (valaciclovir) associée à une corticothérapie et l’évolution était très favorable. Le pronostic de la nécrose rétinienne aiguë ou ARN syndrome est le plus souvent sévère. Le traitement de cette affection doit être le plus précoce possible afin de limiter une bilatéralisation et la survenue des complications. Cette observation confirme que la thérapie orale antivirale (valaciclovir, famciclovir et valganciclovir) sans traitement intraveineux initial est un traitement efficace de l’ARN.

Correlation of Clinical Outcomes with Quantitative Polymerase Chain Reaction DNA Copy Number in Patients with Acute Retinal Necrosis

PURPOSE

To correlate visual acuity outcomes and clinical features with quantitative PCR DNA copy number in patients with acute retinal necrosis (ARN).

METHODS

Retrospective, consecutive case series.

RESULTS

In total, 14 eyes of 13 patients were diagnosed with ARN, based on the American Uveitis Society criteria, and were followed for a mean of 324.5 days (median 250.5 days, SD ± 214 days). Anterior chamber fluid analyzed by quantitative PCR identified viral DNA in 11 of 14 eyes (78.5%). Varicella zoster virus (VZV) was identified in seven eyes (50%) and herpes simplex virus (HSV) in four eyes (28.5%). Mean DNA copy number was 7.9 × 10⁶/mL (median 2.10 × 10⁶/mL, range: 0-5.60 × 10⁷/mL). Eyes with quantitative PCR DNA copy number of ≥5.0 × 10⁶/mL (n = 6 eyes) had worse baseline visual acuity (logMAR 1.48 ± 0.71 vs 0.94 ± 0.76, p = 0.196) and final visual acuity (logMAR 2.10 ± 0.60 vs 0.82 ± 0.81, p = 0.007) compared with patients with a DNA copy number <5.0 × 10⁶/mL (n = 8 eyes). Patients with a DNA copy number of ≥5.0 × 10⁶/mL were more likely to have at least 5 clock hours of retinitis on funduscopic exam (p = 0.03) and developed retinal detachment more frequently (p = 0.08).

CONCLUSIONS

Quantitative DNA copy number of ≥5.0 × 10⁶/mL is associated with more extensive retinitis, worse visual acuity, and development of retinal detachment in patients with acute retinal necrosis.

Acute Retinal Necrosis: Diagnostic and Treatment Strategies in Germany

PURPOSE

To analyze the preferred practice respective diagnosis, treatment, and complications in patients with acute retinal necrosis in Germany.

METHODS

The uveitis-section of the German Ophthalmologic Society developed a questionnaire with 12 questions concerning patients with acute retinal necrosis seen in the 5 years up to August 2009.

RESULTS

In total, 35 eye hospitals answered the questionnaire and reported 213 patients with acute retinal necrosis. Diagnosis was made clinically in 86%. Anterior chamber tap, vitreous biopsy, diagnostic vitrectomy, and serology were performed for confirmation. Therapy was started with acyclovir in all institutions, and continued with ganciclovir, foscarnet and brivudine in some cases. Intravitreal injections were performed in 46%. Additional oral steroids were given in 80%. A following oral antiviral treatment was performed in 94%.

CONCLUSIONS

Relevant variations were seen in diagnosis and treatment practices. The survey outlines the need for a unique diagnostic and therapeutic guideline.

Current aspects on the management of viral uveitis in immunocompetent individuals

Viruses are a fundamental etiology of ocular inflammation, which may affect all structures of the organ. Advances in molecular diagnostics reveal an increasingly broader spectrum of virus-associated intraocular inflammation, including all members of the herpes family, rubella virus, and other more rare causes such as Epstein–Barr and chikungunya virus. In particular, viruses of the herpes family are important causes of anterior and posterior uveitis. Owing to their often fulminant clinical course and persistence in ocular tissues, a clear differential diagnosis between alpha- and beta-type herpes viruses is essential to guide acute and long-term treatment. Here, we review the epidemiology, clinical, and laboratory findings of virus-associated uveitis with emphasis on their therapy and management and include our own experience.

A systematic approach to emergencies in uveitis

Uveitis is a common cause of preventable blindness although it is consider a sight-threatening condition particularly in cases with posterior segment inflammation. To deal with emergency conditions in uveitis, we must aware of the essential signs and symptoms that reflect a true uveitic emergency. Failure to recognize these essential signs and symptoms of a true uveitic emergency may result in a devastating visual outcome. This review provides general ophthalmologists and residents, clinical guidelines for the main uveitic entities that require immediate recognition and urgent intervention in the emergency room to prevent severe permanent visual loss.

Functional characterization of ocular-derived human alphaherpesvirus cross-reactive CD4 T cells

Intraocular varicella-zoster virus (VZV) and HSV type 1 (HSV-1) infections cause sight-threatening uveitis. The disease is characterized by an intraocular inflammatory response involving herpesvirus-specific T cells. T cell reactivity to the noncausative human alphaherpesvirus (αHHV) is commonly detected in the affected eyes of herpetic uveitis patients, suggesting the role of cross-reactive T cells in the disease. This study aimed to identify and functionally characterize intraocular human alphaherpesvirus cross-reactive T cells. VZV protein immediate early 62 (IE62), which shares extensive homology with HSV ICP4, is a previously identified T cell target in VZV uveitis. Two VZV-specific CD4 T cell clones (TCC), recovered from the eye of a VZV uveitis patient, recognized the same IE62918-927 peptide using different TCR and HLA-DR alleles. The IE62918-927 peptide bound with high affinity to multiple HLA-DR alleles and was recognized by blood-derived T cells of 5 of 17 HSV-1/VZV-seropositive healthy adults but not in cord blood donors (n = 5). Despite complete conservation of the IE62 epitope in the orthologous protein ICP4 of HSV-1 and HSV-2, the TCC recognized VZV and HSV-1- but not HSV-2-infected B cells. This was not attributed to proximal epitope-flanking amino acid polymorphisms in HSV-2 ICP4. Notably, VZV/HSV-1 cross-reactive CD4 T cells controlled VZV but not HSV-1 infection of human primary retinal pigment epithelium (RPE) cells. In conclusion, we report on the first VZV/HSV-1 cross-reactive CD4 T cell epitope, which is HLA-DR promiscuous and immunoprevalent in coinfected individuals. Moreover, ocular-derived peptide-specific CD4 TCC controlled VZV but not HSV-1 infection of RPE cells, suggesting that HSV-1 actively inhibits CD4 T cell activation by infected human RPE cells.