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Wei H, Xu W, Jiang H, Jin S, Liu X. Prognostic factors associated with acute retinal necrosis treated non-surgically. Eye (Lond) 2024:10.1038/s41433-024-03319-3. [PMID: 39261652 DOI: 10.1038/s41433-024-03319-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 07/30/2024] [Accepted: 09/03/2024] [Indexed: 09/13/2024] Open
Abstract
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.
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Affiliation(s)
- Haihui Wei
- Ophthalmologic Center of the Second Hospital, Jilin University, Changchun, PR China
| | - WenJing Xu
- Ophthalmologic Center of the Second Hospital, Jilin University, Changchun, PR China
| | - Hai Jiang
- Ophthalmologic Center of the Second Hospital, Jilin University, Changchun, PR China
| | - Siyan Jin
- Ophthalmologic Center of the Second Hospital, Jilin University, Changchun, PR China
| | - Xiaoli Liu
- Ophthalmologic Center of the Second Hospital, Jilin University, Changchun, PR China.
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Servillo A, Berni A, Marchese A, Bodaghi B, Khairallah M, Read RW, Miserocchi E. Posterior Herpetic Uveitis: A Comprehensive Review. Ocul Immunol Inflamm 2023; 31:1461-1472. [PMID: 37364039 DOI: 10.1080/09273948.2023.2221338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
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.
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Affiliation(s)
- Andrea Servillo
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Berni
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Marchese
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Paris, France
| | - Moncef Khairallah
- Department of Ophthalmology, Fattouma Bourguiba University Hospital, Faculty of Medicine, University of Monastir, Monastir, Tunisia
| | - Russell W Read
- Department of Ophthalmology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Elisabetta Miserocchi
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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Mishra SB, Mahendradas P, Kawali A, Sanjay S, Shetty R. Reactivation of varicella zoster infection presenting as acute retinal necrosis post COVID 19 vaccination in an Asian Indian male. Eur J Ophthalmol 2023; 33:NP32-NP36. [PMID: 34541931 DOI: 10.1177/11206721211046485] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE To present the clinical features of a rare case of varicella zoster infection following one dose of Coronavirus Disease 2019 (COVID-19) vaccination in an elderly Asian Indian male. METHODS Retrospective observational case report. RESULTS A 71-year-old gentleman presented to us with complaints of reduced vision associated with redness and pain in his right eye for 1 week. On examination he revealed a right eye pan uveitis picture with circumcorneal congestion, multiple fine keratic precipitates, anterior chamber cells and flare, vitritis and widespread areas of acute retinal necrosis. His left eye was within normal limits. Ten days prior to the presentation he had received the first dose of COVID-19 vaccine following which he had developed fever for 2 days that preceded the red eye. The patient's aqueous sample tested positive for varicella zoster virus (VZV) by nested polymerase chain reaction (PCR) method. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in reverse transcriptase polymerase chain reaction (RT-PCR) assay from the aqueous and also from the nasopharyngeal swab was negative. CONCLUSION AND SIGNIFICANCE To the best of our knowledge this is the earliest description of a case that has a viral reactivation following COVID-19 vaccination. Elderly people with pre-existing comorbidities, may be at a risk of both primary coronavirus infection and unconceivable risk of aberrant immune reactions leading to a different virus infection or reactivation need to be kept in mind. We present a possible link between SARS-CoV-2 virus vaccination and varicella zoster reactivation in this patient.
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Affiliation(s)
- Sai Bhakti Mishra
- Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Padmamalini Mahendradas
- Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Ankush Kawali
- Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Srinivasan Sanjay
- Department of Uveitis and Ocular Immunology, Narayana Nethralaya, Bengaluru, Karnataka, India
| | - Rohit Shetty
- Department of Cornea and Neurophthalmology, Narayana Nethralaya, Bengaluru, Karnataka, India
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Gueudry J, Bodaghi B. Advances in the microbiological diagnosis of herpetic retinitis. FRONTIERS IN OPHTHALMOLOGY 2022; 2:990240. [PMID: 38983563 PMCID: PMC11182275 DOI: 10.3389/fopht.2022.990240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/24/2022] [Indexed: 07/11/2024]
Abstract
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.
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Affiliation(s)
- Julie Gueudry
- Department of Ophthalmology - Charles Nicolle University Hospital, CHU Charles Nicolle, Rouen, France
| | - Bahram Bodaghi
- Department of Ophthalmology, DHU ViewRestore, Sorbonne Université, Pitié Salpêtrière Hospital, Paris, France
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Classification Criteria for Acute Retinal Necrosis Syndrome. Am J Ophthalmol 2021; 228:237-244. [PMID: 33845012 PMCID: PMC8675365 DOI: 10.1016/j.ajo.2021.03.057] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 01/29/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine classification criteria for acute retinal necrosis (ARN). DESIGN Machine learning of cases with ARN and 4 other infectious posterior uveitides / panuveitides. METHODS Cases of infectious posterior uveitides / panuveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the infectious posterior uveitides / panuveitides. The resulting criteria were evaluated on the validation set. RESULTS Eight hundred three cases of infectious posterior uveitides / panuveitides, including 186 cases of ARN, were evaluated by machine learning. Key criteria for ARN included (1) peripheral necrotizing retinitis and either (2) polymerase chain reaction assay of an intraocular fluid specimen positive for either herpes simplex virus or varicella zoster virus or (3) a characteristic clinical appearance with circumferential or confluent retinitis, retinal vascular sheathing and/or occlusion, and more than minimal vitritis. Overall accuracy for infectious posterior uveitides / panuveitides was 92.1% in the training set and 93.3% (95% confidence interval 88.2, 96.3) in the validation set. The misclassification rates for ARN were 15% in the training set and 11.5% in the validation set. CONCLUSIONS The criteria for ARN had a reasonably low misclassification rate and seemed to perform sufficiently well for use in clinical and translational research.
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Moharana B, Dogra M, Singh SR, Ravikumar B, Tigari B, Katoch D, Singh A, Singh R. Outcomes of 25-gauge pars plana vitrectomy with encircling scleral band for acute retinal necrosis-related rhegmatogenous retinal detachment. Indian J Ophthalmol 2021; 69:635-640. [PMID: 33595491 PMCID: PMC7942078 DOI: 10.4103/ijo.ijo_1353_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/21/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022] Open
Abstract
Purpose The aim of this study was to evaluate the anatomic and functional outcomes of 25-gauge pars plana vitrectomy (25G PPV) with encircling scleral band (ESB) in patients with acute retinal necrosis (ARN)-related rhegmatogenous retinal detachment (RRD). Methods Single-center retrospective interventional case series of patients who underwent 25G PPV with ESB for ARN-related RRD. Complete anatomic success was defined as the complete attachment of retina after primary PPV. Functional success was measured by the final best-corrected visual acuity (BCVA) ≥20/400. Intraoperative and postoperative complications were also noted. Results 14 eyes of 13 patients were included in the study. Six patients (46.1%) were immunocompromised. The mean follow-up was 23.64 ± 9.95 (range 6-42) months. Silicone oil was used as tamponade in 13 eyes and C3F8gas in one eye. After the primary PPV, complete anatomical success was seen in all eyes (100%), however, one eye developed phthisis bulbi after silicone oil removal (SOR). Statistically significant improvement of BCVA was seen, from LogMAR 2.03 ± 0.29 preoperatively to LogMAR 1.57 ± 0.63 postoperatively (p-value 0.014). Six eyes (42.9%) had functional success. Nine eyes (64.3%) had improvement in vision while 4 eyes (28.6%) maintained preoperative vision. 10 eyes (71.4%) underwent cataract surgery, nine eyes (64.3%) underwent SOR while 2 eyes (14.3%) had epiretinal membrane (ERM) under oil during follow-up. Conclusion 25G PPV combines the advantages of minimally invasive vitrectomy surgery while offering improved anatomic outcomes in patients with ARN-related RRD. The functional outcome varies depending on the status of the optic disc and macula.
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Affiliation(s)
- Bruttendu Moharana
- Department of Ophthalmology, Drishti Eye Hospital, Panchkula, Haryana, India
| | - Mohit Dogra
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Simar Rajan Singh
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhukya Ravikumar
- Department of Ophthalmology, Dr R. P. Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
| | - Basavaraj Tigari
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deeksha Katoch
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Singh
- Department of Ophthalmology, All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India
| | - Ramandeep Singh
- Department of Ophthalmology, Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- This Study was Conducted at Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Hedayatfar A, Ebrahimiadib N, Zarei M, Ashraf Khorasani M, Mahbod M, Asgari S, Sedaghat A. Acute retinal necrosis: Clinical manifestation and long-term visual outcomes in a series of polymerase chain reaction-positive patients. Eur J Ophthalmol 2020; 31:1961-1969. [PMID: 32567354 DOI: 10.1177/1120672120936181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Alireza Hedayatfar
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran.,Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Nazanin Ebrahimiadib
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Zarei
- Retina Service, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Ashraf Khorasani
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | - Soheila Asgari
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Ahad Sedaghat
- Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Vasudevan A, Rojas-Moreno C, Tarun T. Acute retinal necrosis secondary to Varicella Zoster Virus. IDCases 2019; 18:e00585. [PMID: 31338301 PMCID: PMC6630083 DOI: 10.1016/j.idcr.2019.e00585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 11/25/2022] Open
Abstract
A 54 year old female presented to the ophthalmology clinic with pain and decreased vision in her left eye. No past medical history other than primary varicella zoster infection, in her childhood. The eye exam revealed a macular region with scattered areas of retinal opacity along with patches of necrosis on the periphery. She was started on valganciclovir and referred to the infectious disease clinic. Cell Count, blood chemistry and HIV were negative. Serum was sent for polymerase chain reaction (PCR) for Varicella Zoster Virus (VZV), Herpes Simplex Virus (HSV) and Cytomegalovirus (CMV). The VZV PCR was positive. She had decreased vision on the right eye two days later, and exam revealed peripheral retinal whitening. She was admitted and started on intravenous acyclovir. VZV is one of the most common causes of ARN and has been described in both immunocompetent and immunocompromised persons. Visual changes are usually noted weeks to months after the antecedent herpes zoster. Retinal involvement is bilateral in over half of cases, suggesting that VZV reaches the central nervous system hematogenously. The retinal exam reveals multifocal necrotizing lesions, often initially involving the peripheral retina. Therapy includes intravenous acyclovir with consideration of intravitreal foscarnet and other antivirals for progressing disease.
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Affiliation(s)
- Archana Vasudevan
- Division of Infectious Diseases, Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, United States
| | - Christian Rojas-Moreno
- Division of Infectious Diseases, Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, United States
| | - Tushar Tarun
- Division of Cardiology, Department of Medicine, University of Missouri, One Hospital Drive, Columbia, MO, 65212, United States
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Kim DY, Jo J, Joe SG, Lee JY, Yoon YH, Kim JG. Clinical feature and visual prognosis of acute retinal necrosis according to the initially involved zone and extent: 10-year experience. Eur J Ophthalmol 2018; 29:244-250. [DOI: 10.1177/1120672118787438] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: We aimed to analyze the visual prognosis and clinical characteristics of acute retinal necrosis according to the initially involved zone and extent. Study design: Retrospective, consecutive, cross-sectional study. Methods: We retrospectively reviewed acute retinal necrosis patients who were treated with systemic antiviral treatment, and assessed the visual prognosis of acute retinal necrosis following antiviral treatment based on the initially involved zone and the extent of acute retinal necrosis at the time of diagnosis. Moreover, we evaluated whether prophylactic laser photocoagulation had preventive effects on retinal detachment. Results: A total of 43 eyes from 35 patients with acute retinal necrosis were included. Eyes with zone I involvement/extensive retinal lesions showed poor visual prognosis (logMAR: 1.17 ± 0.97 vs 0.49 ± 0.81; p = 0.014) and a higher incidence of retinal detachment (9/30 (30.0%) vs 0/13 (0%); p = 0.039) after treatment. Retinal detachment was observed in 20.9% of cases, and its incidence was significantly lower in eyes that had undergone prophylactic laser photocoagulation. Conclusion: The overall visual prognosis of acute retinal necrosis is poor and can be determined at the time of diagnosis. Prophylactic laser photocoagulation exhibits preventive effects with regard to the development of retinal detachment. Therefore, laser photocoagulation should be actively considered in eyes with extensive retinal lesions to prevent retinal detachment and thus eventually improve the overall visual prognosis of acute retinal necrosis.
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Affiliation(s)
- Dong Yoon Kim
- Department of Ophthalmology, Chungbuk National University Hospital, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jaehyuck Jo
- Department of Ophthalmology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Soo Geun Joe
- Department of Ophthalmology, Gangneung Asan Hospital, College of Medicine, University of Ulsan, Gangneung, Korea
| | - Joo Yong Lee
- Department of Ophthalmology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Young Hee Yoon
- Department of Ophthalmology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - June-Gone Kim
- Department of Ophthalmology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Wong RW, Jumper JM, McDonald HR, Johnson RN, Fu A, Lujan BJ, Cunningham ET. Emerging concepts in the management of acute retinal necrosis. Postgrad Med J 2018; 89:478-85. [PMID: 23861500 DOI: 10.1136/postgradmedj-2012-301983rep] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Acute retinal necrosis (ARN), also known as Kirisawa-type uveitis, is an uncommon condition caused by infection of the retina by one of the herpes family of viruses, most typically varicella zoster virus or herpes simplex virus and less commonly cytomegalovirus. Clinical diagnosis can be challenging and is often aided by PCR-based analysis of ocular fluids. Treatment typically involves extended use of one or more antiviral agents. Long term retinal detachment risk is high. We review the literature on ARN and present an approach to the diagnosis and management of this serious condition.
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Teh SW, Mok PL, Abd Rashid M, Bastion MLC, Ibrahim N, Higuchi A, Murugan K, Mariappan R, Subbiah SK. Recent Updates on Treatment of Ocular Microbial Infections by Stem Cell Therapy: A Review. Int J Mol Sci 2018; 19:ijms19020558. [PMID: 29438279 PMCID: PMC5855780 DOI: 10.3390/ijms19020558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/03/2017] [Accepted: 12/12/2017] [Indexed: 02/06/2023] Open
Abstract
Ocular microbial infection has emerged as a major public health crisis during the past two decades. A variety of causative agents can cause ocular microbial infections; which are characterized by persistent and destructive inflammation of the ocular tissue; progressive visual disturbance; and may result in loss of visual function in patients if early and effective treatments are not received. The conventional therapeutic approaches to treat vision impairment and blindness resulting from microbial infections involve antimicrobial therapy to eliminate the offending pathogens or in severe cases; by surgical methods and retinal prosthesis replacing of the infected area. In cases where there is concurrent inflammation, once infection is controlled, anti-inflammatory agents are indicated to reduce ocular damage from inflammation which ensues. Despite advances in medical research; progress in the control of ocular microbial infections remains slow. The varying level of ocular tissue recovery in individuals and the incomplete visual functional restoration indicate the chief limitations of current strategies. The development of a more extensive therapy is needed to help in healing to regain vision in patients. Stem cells are multipotent stromal cells that can give rise to a vast variety of cell types following proper differentiation protocol. Stem cell therapy shows promise in reducing inflammation and repairing tissue damage on the eye caused by microbial infections by its ability to modulate immune response and promote tissue regeneration. This article reviews a selected list of common infectious agents affecting the eye; which include fungi; viruses; parasites and bacteria with the aim of discussing the current antimicrobial treatments and the associated therapeutic challenges. We also provide recent updates of the advances in stem cells studies on sepsis therapy as a suggestion of optimum treatment regime for ocular microbial infections.
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Affiliation(s)
- Seoh Wei Teh
- Department of Biomedical Science, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
| | - Pooi Ling Mok
- Department of Biomedical Science, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
- Genetics and Regenerative Medicine Research Centre, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Aljouf University, 72442 Sakaka, Aljouf Province, Saudi Arabia.
| | - Munirah Abd Rashid
- Department of Ophthalmology, Faculty of Medicine, UKM Medical Center, 56000 Cheras, Kuala Lumpur, Malaysia.
| | - Mae-Lynn Catherine Bastion
- Department of Ophthalmology, Faculty of Medicine, UKM Medical Center, 56000 Cheras, Kuala Lumpur, Malaysia.
| | - Normala Ibrahim
- Department of Psychiatry, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
| | - Akon Higuchi
- Department of Chemical and Materials Engineering, National Central University, No. 300, Jhongda RD., Jhongli, 32001 Taoyuan, Taiwan.
| | - Kadarkarai Murugan
- Department of Zoology, Thiruvalluvar University, Serkkadu, 632 115 Vellore, India.
| | - Rajan Mariappan
- Biomaterials in Medicinal Chemistry Laboratory, Department of Natural Products Chemistry, School of Chemistry, Madurai Kamaraj University, Madurai, 625 021 Tamil Nadu, India.
| | - Suresh Kumar Subbiah
- Genetics and Regenerative Medicine Research Centre, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
- Department of Medical Microbiology and Parasitology, Universiti Putra Malaysia, 43400 UPM Serdang, Selangor, Malaysia.
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12
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Lee JY, Kim DY, Lee HJ, Jeong JH, Park SP, Kim JY. Atypical acute retinal necrosis accompanied by Terson's syndrome: a case report. BMC Ophthalmol 2017; 17:255. [PMID: 29258454 PMCID: PMC5735939 DOI: 10.1186/s12886-017-0655-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 12/11/2017] [Indexed: 07/11/2024] Open
Abstract
Background Acute retinal necrosis (ARN) has characterized by panuveitis, vitritis, severe vaso-occlusive vasculitis, and diffuse necrotizing retinitis. There are no case reports on atypical ARN combined with Terson’s syndrome. Herein, we report a case of ARN with atypical clinical features combined with Terson’s syndrome that we successfully treated by intravitreal ganciclovir injection. Case presentation A 64-year-old man visited our eye clinic with a complaint of decreased visual acuity in his right eye. At the initial visit, his best corrected visual acuity was 20/125 in the right eye. Slit-lamp examination demonstrated mild hyperemia, keratic precipitates, and anterior chamber inflammatory reaction. Fundus examination revealed multiple diffuse white-yellowish infiltrations in the peripheral retina combined with dot hemorrhages. Ultra-wide-field fluorescence angiography showed obstructive arteritis with peripheral non-perfusion and leakage from the retinal vessels. As a result of the PCR analysis, varicella zoster virus DNA was identified in the aqueous humor. Under the diagnosis with VZV-mediated ARN, we started with intravenous acyclovir and oral prednisolone. After 3 days of the above treatment, the anterior chamber inflammation and vitreous opacity were increased. On fundus examination, multiple whitish infiltrations were increased. In addition, newly developed vitreous and peripapillary hemorrhages were detected. On the T2 brain magnetic resonance imaging (MRI) demonstrated a sub-acute or old hemorrhagic infarction in the right occipital lobe, and contrast-enhancing lesions in the right basal ganglia. The spinal tapping was performed in the department of neurology in our hospital at the time when the patient complained of headache, and intracranial pressure was 31 mmHg. Under the diagnosis of ARN with Terson’s syndrome, we started intravitreal ganciclovir (2 mg/0.5 ml) injections. After 5 intravitreal ganciclovir injections over a period of 8 months, the diffuse whitish infiltrating retinal lesions combined with dot hemorrhage were decreased. The vitreous and peripapillary hemorrhage was significantly reduced. There was no recurrence in the patient’s right eye, in which his visual acuity had improved to 20/60. Conclusions In the event of a poor response to traditional treatment such as intravenous acyclovir, intravitreal ganciclovir may have a role as an adjunctive therapy in patients of VZV associated ARN combined with Terson’s syndrome.
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Affiliation(s)
- Jong Young Lee
- Department of Ophthalmology, Jeju National University Hospital, Jeju National University School of Medicine, 1753-3 Ara-1 Dong, Jeju-Si, Jeju Self-Governing Province, Republic of Korea
| | - Dong Yoon Kim
- Department of Ophthalmology, Chungbuk National University College of Medicine, Cheongju, South Korea
| | - Hye Jin Lee
- Department of Ophthalmology, Jeju National University Hospital, Jeju National University School of Medicine, 1753-3 Ara-1 Dong, Jeju-Si, Jeju Self-Governing Province, Republic of Korea
| | - Jin Ho Jeong
- Department of Ophthalmology, Jeju National University Hospital, Jeju National University School of Medicine, 1753-3 Ara-1 Dong, Jeju-Si, Jeju Self-Governing Province, Republic of Korea
| | - Sung Pyo Park
- Department of Ophthalmology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Jin Young Kim
- Department of Ophthalmology, Jeju National University Hospital, Jeju National University School of Medicine, 1753-3 Ara-1 Dong, Jeju-Si, Jeju Self-Governing Province, Republic of Korea.
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Graybill C, Claypool DJ, Brinton JT, Levin MJ, Lee KS. Cytokines Produced in Response to Varicella-Zoster Virus Infection of ARPE-19 Cells Stimulate Lymphocyte Chemotaxis. J Infect Dis 2017; 216:1038-1047. [PMID: 28968855 DOI: 10.1093/infdis/jix426] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/15/2017] [Indexed: 12/14/2022] Open
Abstract
Posterior uveitis is an ocular complication that can occur with reactivation of varicella-zoster virus (VZV). It may lead to loss of vision due to retinal detachment and chronic inflammation, which often causes more severe disease than the virus infection itself. To increase our understanding of the immune response, we infected the retinal pigment epithelial (RPE) cell line, ARPE-19, with cell-associated VZV and compared its response to that of the MeWo cell line using multiplex assays. We observed (1) a difference in the magnitude and kinetics of cytokine responses between the 2 cell types and (2) differential migration of CD4+ and CD8+ T cells towards these cytokines. Thus, our data provide information about the cytokine and lymphocytic responses to VZV infection of RPE cells, thereby providing a useful platform for future studies to address mechanisms underlying the immunopathology of VZV-associated posterior uveitis.
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Affiliation(s)
| | | | - John T Brinton
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado Denver Anschutz Medical Campus, Aurora
| | - Myron J Levin
- Department of Pediatrics, Section of Infectious Diseases
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Huang JM, Callanan P, Callanan D, Wang RC. Rate of Retinal Detachment after Early Prophylactic Vitrectomy for Acute Retinal Necrosis. Ocul Immunol Inflamm 2016; 26:204-207. [DOI: 10.1080/09273948.2016.1202986] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jason Mingyi Huang
- Department of Ophthalmology, The University of Texas Southwestern Medical Center, Dallas, TX, Texas, USA
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Kopplin LJ, Thomas AS, Cramer S, Kim YH, Yeh S, Lauer AK, Flaxel CJ. Long-Term Surgical Outcomes of Retinal Detachment Associated With Acute Retinal Necrosis. Ophthalmic Surg Lasers Imaging Retina 2016; 47:660-4. [DOI: 10.3928/23258160-20160707-08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 05/06/2016] [Indexed: 11/20/2022]
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Abstract
Antiviral drug discovery has produced a series of drugs active against herpesviruses in vitro. Several of these are now licensed and/or have been used in clinical practice. This article reviews the mechanisms of action of acyclovir, ganciclovir, penciclovir, sorivudine and foscarnet, the development of resistance to these drugs and their pharmacokinetic and cellular toxicities. Based upon the natural histories of HSV, VZV and CMV, treatment objectives for each virus are discussed and the performance of each drug matched against these objectives. Overall, it is concluded that the perfect drug for treating herpesviruses does not exist, but that significant progress has been made towards controlling several herpesvirus diseases. It is suggested that further progress will require not just improved drug discovery programmes, but also an understanding of different pathogeneses and an appreciation by practising physicians that antiviral drugs must be given early in the infectious process to achieve the best results.
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Affiliation(s)
- P.D. Griffiths
- Royal Free Hospital School of Medicine, Rowland Hill Street, London NW3 2PF, UK
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Hyun SY, Kim DY, Chae JB. Multiple Serous Chorioretinopathy after Facial Herpes Zoster. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.1.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sang Yoon Hyun
- Department of Ophthalmology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Dong Yoon Kim
- Department of Ophthalmology, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ju Byung Chae
- Department of Ophthalmology, Chungbuk National University College of Medicine, Cheongju, Korea
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Sogawa T, Hashida N, Sawa M, Nishida K. Rare Association of Perivascular Granulomatous Lesions in a Patient with Acute Retinal Necrosis. Case Rep Ophthalmol 2015; 6:373-9. [PMID: 26668578 PMCID: PMC4677696 DOI: 10.1159/000442084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Purpose The aim of this study was to examine sequential changes in perivascular granulomatous lesions with acute retinal necrosis (ARN). Methods A healthy 46-year-old Japanese woman, who developed floaters and pain in her left eye, underwent optical coherence tomography (OCT), fluorescein angiography, and routine ophthalmological examinations. Treatment-associated changes in perivascular granulomatous lesions were monitored using spectral-domain (SD)-OCT. Results The patient had no previous ophthalmic history, and her general condition was good. A slit-lamp examination revealed keratic precipitates and aqueous cells (2+) in the left eye. A fundus examination showed yellow-white patches of necrotizing retinal lesions in the temporal upper area, retinal arteritis, retinal hemorrhage, and vitreous opacities. The patient was diagnosed with ARN according to diagnostic criteria. SD-OCT images confirmed high-intensity and uniform granulomatous deposits in the perivascular area and fovea. Systemic corticosteroids and antiviral therapy were initiated, resulting in the gradual resolution of granulomatous lesions. The patient continues to be followed untreated without evidence of recurrence, retinal detachment, or active inflammation. Conclusions This is the first report of perivascular granulomatous lesions in a patient with ARN. Our results showed that the formation of granulomas may be induced in the retina of ARN patients without fulminant inflammation.
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Affiliation(s)
- Takahiro Sogawa
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriyasu Hashida
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Miki Sawa
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kohji Nishida
- Department of Ophthalmology, Osaka University Graduate School of Medicine, Osaka, Japan
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Takase H, Mochizuki M. Factors associated with progression and outcome of acute retinal necrosis. EXPERT REVIEW OF OPHTHALMOLOGY 2015. [DOI: 10.1586/17469899.2015.1057814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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20
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Al-Dhibi HA, Al-Mahmood AM, Arevalo JF. A systematic approach to emergencies in uveitis. Middle East Afr J Ophthalmol 2014; 21:251-8. [PMID: 25100911 PMCID: PMC4123279 DOI: 10.4103/0974-9233.134687] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Hassan A Al-Dhibi
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - Ammar M Al-Mahmood
- Division of Anterior Segment and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | - J Fernando Arevalo
- Division of Vitreoretinal Surgery and Uveitis, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia ; Retina Division, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Janani MK, Malathi J, Biswas J, Sridharan S, Madhavan HN. Genotypic Detection of Epstein Barr Virus from Clinically Suspected Viral Retinitis Patients in a Tertiary Eye Care Centre, India. Ocul Immunol Inflamm 2014; 23:384-91. [PMID: 25325148 DOI: 10.3109/09273948.2014.968265] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To evaluate the diagnostic value of PCR on aqueous humour for detection and genotyping of Epstein Bar Virus in patients with viral retinitis. METHODS 70 AH samples were collected from 20 HIV positive patients with clinically suspected viral retinitis and 25 patients with serpignous choroiditis and 25 AH from patients undergoing cataract surgery. PCR was performed to screen HHV-1 to HHV-5, Mtb and Toxoplasma gondii. Genotype prevalence was confirmed by phylogenetic analysis targetig EBV. RESULTS EBV was detected in 17 (37.7%) samples. Genotyping to subtype EBV, revealed the circulation of only one subtype (Type 1). PCR results for other infective agents were negative except for the presence of CMV in 5 (11.1%) AH. CONCLUSION The application of PCR to detect genotypes can be used as an epidemiological tool for clinical management. To our knowledge this is the first report on genotyping of EBV performed on intra ocular samples.
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Affiliation(s)
| | - Jambulingam Malathi
- a Vision Research Foundation, L&T Microbiology Research Centre , Sankara Nethralaya , Chennai , India
| | - Jyothirmay Biswas
- a Vision Research Foundation, L&T Microbiology Research Centre , Sankara Nethralaya , Chennai , India
| | - Sudharshan Sridharan
- a Vision Research Foundation, L&T Microbiology Research Centre , Sankara Nethralaya , Chennai , India
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Yeh S, Suhler EB, Smith JR, Bruce B, Fahle G, Bailey ST, Hwang TS, Stout JT, Lauer AK, Wilson DJ, Rosenbaum JT, Flaxel CJ. Combination Systemic and Intravitreal Antiviral Therapy in the Management of Acute Retinal Necrosis Syndrome. Ophthalmic Surg Lasers Imaging Retina 2014; 45:399-407. [DOI: 10.3928/23258160-20140908-02] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 06/26/2014] [Indexed: 11/20/2022]
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Roy R, Pal BP, Mathur G, Rao C, Das D, Biswas J. Acute Retinal Necrosis: Clinical Features, Management and Outcomes – a 10 Year Consecutive Case Series. Ocul Immunol Inflamm 2014; 22:170-4. [DOI: 10.3109/09273948.2013.819928] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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24
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Ouwendijk WJD, Geluk A, Smits SL, Getu S, Osterhaus ADME, Verjans GMGM. Functional characterization of ocular-derived human alphaherpesvirus cross-reactive CD4 T cells. THE JOURNAL OF IMMUNOLOGY 2014; 192:3730-9. [PMID: 24623134 DOI: 10.4049/jimmunol.1302307] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Werner J D Ouwendijk
- Department of Viroscience, Erasmus Medical Center, 3015 CE Rotterdam, The Netherlands
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Mandelcorn ED. Infectious causes of posterior uveitis. Can J Ophthalmol 2013; 48:31-9. [DOI: 10.1016/j.jcjo.2012.11.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/26/2012] [Indexed: 10/26/2022]
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Mathias M, Nagel MA, Khmeleva N, Boyer PJ, Choe A, Durairaj VD, Bennett JL, Mandava N, Gilden D. VZV multifocal vasculopathy with ischemic optic neuropathy, acute retinal necrosis and temporal artery infection in the absence of zoster rash. J Neurol Sci 2013; 325:180-2. [PMID: 23312850 DOI: 10.1016/j.jns.2012.12.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/12/2012] [Indexed: 11/28/2022]
Abstract
We describe a 54-year-old diabetic woman who developed ischemic optic neuropathy followed by acute retinal necrosis and multiple areas of focal venous beading. Vitreous fluid contained amplifiable VZV DNA but not HSV-1, CMV or toxoplasma DNA. The clinical presentation was remarkable for jaw claudication and intermittent scalp pain, prompting a temporal artery biopsy that was pathologically negative for giant cell arteritis, but notable for VZV antigen. The current case adds to the clinical spectrum of multifocal VZV vasculopathy. The development of acute VZV retinal necrosis after ischemic optic neuropathy supports the notion that vasculitis is an important additional mechanism in the development of VZV retinal injury.
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Affiliation(s)
- Marc Mathias
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
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Acute retinal necrosis: factors associated with anatomic and visual outcomes. Jpn J Ophthalmol 2012; 57:98-103. [PMID: 23117419 DOI: 10.1007/s10384-012-0211-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 09/21/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE To examine the factors associated with anatomic and visual outcomes in Japanese patients with acute retinal necrosis (ARN). METHODS One hundred four patients with ARN who were followed for more than 1 year at nine referral centers were reviewed. Retinal involvement at initial presentation was classified into four groups: zone 1 (posterior pole, n = 22), zone 2 (midperiphery, n = 54), zone 3 (periphery, n = 25), and unknown (n = 3). Forty-eight eyes underwent prophylactic vitrectomy before development of retinal detachment (vitrectomy group); 56 eyes were treated conventionally without prophylactic vitrectomy (observation group). RESULTS The retina was attached in 28 of 48 eyes (58.3 %) in the vitrectomy group and 42 of 56 eyes (75.0 %) in the observation group at the final visit (P = 0.071). At 1 year, 56 eyes (53.8 %) had a best-corrected visual acuity (BCVA) of 20/200 or worse. Multivariate logistic regression analyses identified zone 1 disease (odds ratio = 4.983) and optic nerve involvement (odds ratio = 5.084) as significantly associated with BCVA of 20/200 or worse. Among the zone 3 eyes, significantly (P = 0.012) more eyes in the observation group than in the vitrectomy group had an attached retina. CONCLUSIONS Prophylactic vitrectomy did not improve the final BCVA in any eyes. Zone 3 eyes had better outcomes without prophylactic vitrectomy.
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Usui M, Usui N, Goto H, Minoda H, Rai T. Polymerase chain reaction for diagnosis of herpetic intraocular inflammation. Ocul Immunol Inflamm 2012; 1:105-12. [PMID: 22827200 DOI: 10.3109/09273949309086545] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The authors present a polymerase chain reaction method for rapid and direct diagnosis of herpetic intraocular infections using small volume samples of intraocular fluid from 29 patients with various intraocular inflammatory diseases and 24 controls with senile cataract. Of six patients with early acute retinal necrosis from whom aqueous humor was tested, four were found to be positive for the presence of varicella-zoster (VZV) DNA while the other two were positive for the presence of herpes simplex virus (HSV) DNA. One of the patients with HSV DNA had been tested at an extremely early stage, at which time the aqueous humor viral antibody ratio did not predict a specific viral infection. Among four patients with acute retinal necrosis in relatively late stages following treatment with acyclovir from whom vitreous was obtained and tested, only one was found to have the presence of any viral DNA (VZV). On the other hand, the vitreous viral antibody ratio was found to be predictive of VZV infection in all four cases. VZV DNA was also detected in aqueous humor samples from four patients with suspected herpes zoster anterior uveitis, while HSV DNA was found in the aqueous humor of one patient with nonspecific keratouveitis. Neither human cytomegalovirus DNA nor human herpesvirus-6 DNA was detected in any sample included in this study. Finally, Epstein-Barr virus DNA was detected in the aqueous humor of the majority of patients studied and identified in cataract patients as well, suggesting either low specificity of the authors' assay for this virus or ubiquity of this virus in human eyes. In summary, the PCR method proved to be a very useful tool in establishing an etiological diagnosis in patients in the early stages of acute retinal necrosis, and in patients with anterior uveitis due to suspected HSV or VZV infection.
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Affiliation(s)
- M Usui
- Department of Ophthalmology, Tokyo Medical College Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160, Japan
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Luo YH, Duan XC, Chen BH, Tang LS, Guo XJ. Efficacy and necessity of prophylactic vitrectomy for acute retinal necrosis syndrome. Int J Ophthalmol 2012; 5:482-7. [PMID: 22937510 DOI: 10.3980/j.issn.2222-3959.2012.04.15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Accepted: 05/31/2012] [Indexed: 11/02/2022] Open
Abstract
AIM To compare the efficacy of prophylactic vitrectomy for acute retinal necrosis syndrome(ARN) with routine treatment in Chinese patients, thereby investigate the necessity of prophylactic vitrectomy for ARN. METHODS Thirty patients (37 eyes) were retrospectively included in this study. The eyes were divided into 2 groups by treatment, including routine treatment, which consisted of antiviral medication and vitrectomy after retinal detachment (RD) (n=21), and prophylactic vitrectomy, which consisted of antiviral medication and vitrectomy for the prevention of RD performed during the active inflammatory phase (n=16). The extent of necrosis was determined by fundus photographs at the time of presentation (for eyes with mild vitreous opacity) or the drawings in the operation records. Necrosis of the 37 eyes was divided into 3 grades, including peripheral, middle-peripheral and extensive. The follow-up period ranged from 8 to 57 months. Differences in visual acuity and necrosis between groups were identified using independent samples t-test. RESULTS Necrosis was more extensive in the routine treatment group than in the prophylactic vitrectomy group (P<0.05). In the routine treatment group, conservative treatment improved necrosis and prevented RD in 6 eyes (29%). Seven eyes (33%) obtained anatomical success, but retinal redetachment occurred in 8 eyes (57%). There were also 5 eyes (24%) developed ocular hypotony or atrophy. Ten eyes (48%) achieved equal or increased visual acuity. In the prophylactic vitrectomy group, RD occurred in 2 eyes (13%). Twelve eyes (75%) were completely anatomically successful, and 10 eyes underwent silicone oil removal. Only one eye (6%) became ocular hypotony. Fourteen eyes (88%) achieved equal or increased visual acuity. The prophylactic vitrectomy group achieved better vision trends than the routine treatment group (P<0.05). Eyes with peripheral necrosis had better visual outcomes than those with mid-peripheral (P<0.05) or extensive (P<0.05) necrosis. However, there was no significant difference between eyes with mid-peripheral and extensive necrosis (P=0.3008) CONCLUSION Prophylactic vitrectomy can prevent RD and improve the prognosis of ARN, making it an option for cases with rapidly progressing necrosis despite antiviral treatment and cases with moderate to extensive necrosis and severe vitreous opacity.
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Affiliation(s)
- Yong-Heng Luo
- Department of Ophthalmology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Al-Amri AM, Al-Rashaed S, Al-Kharashi S. Acute retinal necrosis after Boston type I keratoprosthesis. Middle East Afr J Ophthalmol 2012; 19:254-7. [PMID: 22623871 PMCID: PMC3353680 DOI: 10.4103/0974-9233.95268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A case report of a 68-year-old male who developed acute retinal necrosis (ARN) after Boston type I keratoprosthesis is presented. The procedure was performed for multiple graft failure secondary to herpetic keratitis. Clinical data including visual acuity, color fundus photography, fluorescein angiography, laboratory tests findings, and management are presented. After exclusion of other causes by laboratory workup, the patient was diagnosed with ARN most likely secondary to herpetic infection. Intravenous acyclovir and oral prednisolone were administered to the patient resulting in marked improvement in visual acuity and regression in the size of the retinitis. The patient eventually developed a soft eye and choroidal detachment with light perception vision. In patients with a history of herpetic keratitis or keratouveitis, it is highly advisable to maintain prophylactic systemic antiviral treatment before and after any ocular procedure such as the Boston keratoprosthesis.
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Affiliation(s)
- Abdullah M Al-Amri
- Vitreoretina and Uveitis Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
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Jeon S, Kakizaki H, Lee WK, Jee D. Effect of Prolonged Oral Acyclovir Treatment in Acute Retinal Necrosis. Ocul Immunol Inflamm 2012; 20:288-92. [DOI: 10.3109/09273948.2012.689073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Witmer MT, Pavan PR, Fouraker BD, Levy-Clarke GA. Acute retinal necrosis associated optic neuropathy. Acta Ophthalmol 2011; 89:599-607. [PMID: 20645925 DOI: 10.1111/j.1755-3768.2010.01911.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Acute retinal necrosis (ARN) syndrome is characterized by severe intraocular inflammation, occlusive vasculopathy and peripheral retinal necrosis. Vision threatening complications of this syndrome include retinal detachment, macular oedema and ischaemia and optic neuropathy. Optic nerve involvement may be the presenting sign of ARN and this condition should be included in the differential diagnosis of acute papillitis. Several mechanisms may lead to ARN associated optic neuropathy including vasculitis, optic nerve ischaemia and direct optic nerve invasion by the herpes virus. We review optic nerve involvement during ARN and present its incidence, pathogenesis, differential diagnosis and treatment.
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Affiliation(s)
- Matthew T Witmer
- Department of Ophthalmology, College of Medicine, University of South Florida, Tampa, Florida, USA.
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T cell responses in experimental viral retinitis: Mechanisms, peculiarities and implications for gene therapy with viral vectors. Prog Retin Eye Res 2011; 30:275-84. [DOI: 10.1016/j.preteyeres.2011.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Revised: 04/17/2011] [Accepted: 04/18/2011] [Indexed: 11/20/2022]
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Witmer MT, Levy-Clarke GA, Fouraker BD, Madow B. Kyrieleis plaques associated with acute retinal necrosis from herpes simplex virus type 2. Retin Cases Brief Rep 2011; 5:297-301. [PMID: 25390418 DOI: 10.1097/icb.0b013e3181f66aac] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To present the case of a 19-year-old woman with acute retinal necrosis syndrome due to herpes simplex virus type 2, who developed segmental periarterial (Kyrieleis) plaques six and one half weeks into her clinical course. METHODS Retrospective case report. PATIENTS Single patient with the diagnosis of acute retinal necrosis syndrome. RESULTS The patient's vitreous biopsy was positive by polymerase chain reaction for herpes simplex virus type 2. DISCUSSION Kyrieleis plaques have been found in the setting of toxoplasmosis, tuberculosis, syphilis, rickettsial disease, herpes zoster virus, intraocular lymphoma, and idiopathic branch retinal artery occlusions. The differential diagnosis for these periarterial plaques should also include herpes simplex virus type 2.
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Affiliation(s)
- Matthew T Witmer
- From the *Department of Ophthalmology, University of South Florida, College of Medicine, Tampa, Florida; and †St. Luke's Cataract and Laser Institute, Tarpon Springs, Florida
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Abedi G, Subramanian ML, Feinberg E, Ness SD. The role of intravenous immunoglobulin in treatment of acute retinal necrosis. Retin Cases Brief Rep 2011; 5:363-365. [PMID: 25390437 DOI: 10.1097/icb.0b013e318217383b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To describe a case of successful treatment of acute retinal necrosis with a combination of antivirals and intravenous immunoglobulin. METHODS This is a case report of a 77-year-old white man diagnosed with unilateral acute retinal necrosis. RESULTS Combination therapy with systemic antivirals, prophylactic laser retinopexy, and intravenous immunoglobulin halted progression of retinitis and preserved visual acuity. CONCLUSION Acute retinal necrosis is an aggressive disease with significant risk of vision loss even when treated with appropriate therapy. In this report, the authors describe a case of successful treatment with a combination of systemic antivirals and intravenous immunoglobulin. Intraocular antiviral injection plus systemic treatment remain to be a more cost-effective option.
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Affiliation(s)
- Gelareh Abedi
- From the *Department of Ophthalmology, School of Medicine, University Health Science Center, San Antonio, Texas; †Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts; and ‡Department of Ophthalmology, School of Medicine, Boston University, Boston, Massachusetts
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Marumoto T, Hiratsuka Y, Murakami A. The significance of the determination of lymphocytes with clinical manifestation of ophthalmic zoster sine herpete. Clin Ophthalmol 2010; 4:817-22. [PMID: 20689799 PMCID: PMC2915869 DOI: 10.2147/opth.s12310] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Indexed: 12/12/2022] Open
Abstract
Objective: To examine the significance of VZV-IgG (IgG) enzyme immunoassay (EIA) and the determination of peripheral blood lymphocyte counts in the diagnosis of ophthalmic zoster sine herpete (ophthalmic ZSH). Method: Clinical case-control study with a sample of 65 patients with ophthalmic ZSH (16 males and 49 females; mean age 56 ± 18 years) in whom pressure elicited pain in tender points of Valleix (tender points of sites at which the trigeminal nerve appears subcutaneously). A total of 41 healthy controls (17 males and 24 females, mean age 48 ± 21 years) were also recruited. In each group, IgG and lymphocyte count were determined upon receiving the consent of patients. Multiple logistic regression analysis was used to evaluate the factors associated with diagnosis of ophthalmic ZSH. Odds ratios and 95% confidence intervals (CI) were determined for each variable. Results: Lymphocyte count in the patients with ophthalmic ZSH was significantly low, though there were no significant differences in age, gender, and IgG between the two groups. Multiple logistic regression analysis revealed that lymphocytes pose a significant prognostic factor, and in case of 1,800 lymphocytes/μl or more, the odds ratio to less than1,800 lymphocytes/μl was 0.29 (95% CI: 0.12–0.72). Conclusion: Patients with orbital pain should be suspected as having ophthalmic ZSH as this allows for the determination of lymphocyte counts after tender points were confirmed. The swift diagnosis of ophthalmic ZSH and the administration of antiviral drugs from an early stage improve the subjective symptoms of the patient and is regarded as necessary to reduce the risk of severe complications.
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Abstract
PURPOSE The purpose of this study was to report long-term visual outcome of acute retinal necrosis. METHODS Medical records of patients with acute retinal necrosis were reviewed. RESULTS Thirty-two patients were diagnosed with acute retinal necrosis from 1998 to 2007. Twenty patients (25 eyes) had at least 1 follow-up and available medical records. Intravitreal injections of ganciclovir and/or foscarnet were administered in 11 of 25 eyes. Intravenous and oral antiviral medications were used in 14 of 20 and 19 of 20 patients, respectively. Eleven of 25 eyes had <25% of retina affected, 8 of 25 had 25% to 50% of retina affected, and 6 of 25 had >50% of retina affected. Mean visual acuity at all time points was best when retinitis involved <25% and decreased as area increased. All but 1 eye with >50% involvement experienced decreased vision regardless of treatment. Three of 4 eyes with 25% to 50% involvement that received intravitreal antivirals had an improvement in visual acuity of > or =2 Snellen lines. Five of 25 eyes developed retinal detachment. None of the six eyes treated with prophylactic laser detached. CONCLUSION Greater extent of retinitis portends a worse visual prognosis. Although intravitreal treatment did not prevent visual acuity loss in patients with severe disease, patients with moderate disease (25-50% retina involved) did well with intravitreal therapy with most having stable or improved visual acuity. Prophylactic laser decreased the rate of detachment.
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Hillenkamp J, Nölle B, Rautenberg P, Fickenscher H, Roider J. [Acute retinal necrosis: Clinical features and therapy options]. Ophthalmologe 2010; 106:1058-64. [PMID: 19820950 DOI: 10.1007/s00347-009-2047-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Varicella zoster virus is the most frequent cause of acute retinal necrosis (ARN) followed by herpes simplex virus. Retinal ischemia and optic nerve atrophy are the main causes of the frequently poor final visual outcome in severe cases of ARN. The clinical diagnosis of ARN should be made as early as possible. Acyclovir should be administered intravenously due to its unreliable oral bioavailability. Systemic corticosteroids should be applied to suppress tissue damage caused by the host's inflammatory response. Severe cases of ARN should be treated by early vitrectomy with diagnostic vitreous biopsy, intravitreal aciclovir lavage, intraoperative laser retinopexy and silicone oil tamponade. The role of prophylactic laser retinopexy for prevention of secondary retinal detachment remains to be determined. The cause of different degrees of severity of ARN is unknown. The degree of severity of ARN is probably an independent predictor of the functional outcome.
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Affiliation(s)
- J Hillenkamp
- Klinik für Ophthalmologie, Universitätsklinikum Schleswig-Holstein, Arnold-Heller Str. 3, Haus 25, 24105, Kiel, Deutschland.
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Hong SM, Yang YS. A case of optic neuritis complicating herpes zoster ophthalmicus in a child. KOREAN JOURNAL OF OPHTHALMOLOGY 2010; 24:126-30. [PMID: 20379464 PMCID: PMC2851001 DOI: 10.3341/kjo.2010.24.2.126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 03/10/2010] [Indexed: 11/23/2022] Open
Abstract
Here we report a case of optic neuritis in the setting of herpes zoster ophthalmicus (HZO) in a child. A six-year-old girl presented with HZO in the right eye. During the hospitalization, her visual acuity decreased. Fluorescein angiography (FAG) and optical coherence tomography revealed optic neuritis in the affected eye. Visual acuity improved with one month of treatment with acyclovir and steroids. FAG analysis showed no evidence of leakage at the optic disc. At one year post treatment, the patient's fundus exam and vision were normal. Therapy with antivirals and steroids may be effective in patients with childhood HZO optic neuritis.
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Affiliation(s)
- Seong Min Hong
- Department of Ophthalmology, Wonkwang University School of Medicine, Iksan, Korea
| | - Yun Sik Yang
- Department of Ophthalmology, Wonkwang University School of Medicine, Iksan, Korea
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Pleyer U, Metzner S, Hofmann J. Diagnostik und Differenzialdiagnostik bei akuter retinaler Nekrose. Ophthalmologe 2009; 106:1074-82. [DOI: 10.1007/s00347-009-2049-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Acute retinal necrosis syndrome (ARN) is a rare retinitis caused by the herpes virus family, including herpes simplex virus and varicella zoster virus. ARN most commonly occurs in otherwise healthy patients of either sex at any age. It is characterized by an initial onset of episcleritis or scleritis, periorbital pain, and a frequently granulomatous anterior uveitis. The key criterion is a necrotizing retinitis starting in the periphery and spreading towards the posterior pole, associated with vitreous opacification. Optic neuropathy may also occur. A total of 75% of untreated eyes develop retinal detachment within the first two months after onset of the disease. Two out of three ARN cases show involvement of the fellow eye. Early intravenous antiviral therapy is mandatory to stop ARN progression. Peripheral retinal breaks can be treated by laser photocoagulation, thereby reducing the risk of retinal detachment. Vitreoretinal surgery is often required, and silicon oil is the tamponade of choice in ARN, resulting in good reattachment rates (90%). Visual prognosis, however, is guarded.
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Ishida T, Sugamoto Y, Sugita S, Mochizuki M. Prophylactic vitrectomy for acute retinal necrosis. Jpn J Ophthalmol 2009; 53:486-9. [PMID: 19847603 DOI: 10.1007/s10384-009-0698-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 03/18/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate the efficacy of prophylactic vitrectomy for acute retinal necrosis. METHODS The clinical charts of 17 patients (18 eyes) with acute retinal necrosis and no retinal break or rhegmatogenous retinal detachment (RRD) were retrospectively analyzed for the efficacy of prophylactic vitrectomy. The retinal necrotic lesions at the initial presentation were classified into three groups according to the lesion site as described by Holland: zone 1 (posterior pole; n = 3), zone 2 (midperiphery; n = 12), and zone 3 (periphery; n = 3). All patients were treated with intravenous antiviral therapy. Three zone 1 eyes and eight zone 2 eyes underwent prophylactic vitrectomy. Four zone 2 eyes and three zone 3 eyes did not receive prophylactic vitrectomy. RESULTS All zone 1 eyes developed RRD despite prophylactic vitrectomy. Among the 12 zone 2 eyes, eight of the eyes that underwent prophylactic vitrectomy did not develop RRD, whereas three of the four zone 2 eyes without prophylactic vitrectomy developed RRD. All zone 3 eyes were cured with only antiviral medication. CONCLUSIONS Prophylactic vitrectomy is effective in preventing the development of RRD in eyes where necrotic lesions do not extend beyond the midperiphery (zone 2).
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Affiliation(s)
- Tomoka Ishida
- Department of Ophthalmology, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Japan
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De La Paz MA, Young LH. Acute Retinal Necrosis Syndrome. Semin Ophthalmol 2009. [DOI: 10.3109/08820539309060211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Holz HA, Espandar L, Moshirfar M. Herpes Zoster Ophthalmicus (HZO). Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00029-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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