Elsevier

Ophthalmology

Volume 114, Issue 4, April 2007, Pages 756-762.e1
Ophthalmology

Original Article
Acute Retinal Necrosis: Features, Management, and Outcomes

https://doi.org/10.1016/j.ophtha.2006.08.037Get rights and content

Objective

To determine the viral diagnosis and factors affecting the visual outcome of eyes with acute retinal necrosis.

Design

Nonrandomized, retrospective, interventional, noncomparative series.

Participants

A cohort of 22 human immunodeficiency virus–negative patients with acute retinal necrosis (ARN). There were 17 unilateral and 5 bilateral cases.

Intervention

Diagnostic vitreous biopsy for polymerase chain reaction (PCR) viral DNA analysis, prophylactic barrier laser posterior to necrotic retina to try to prevent rhegmatogenous retinal detachment (RD), intravenous acyclovir in combination with oral, and vitrectomy for RD repair.

Main Outcome Measures

Results of PCR viral DNA analysis, relationship between prophylactic barrier argon laser photocoagulation and occurrence of RD, and visual acuities at presentation and follow-up.

Results

Varicella–zoster virus (VZV) was detected in 66.7% (12/18) of eyes (66.7% of patients [10/15]) with vitreous biopsy and herpes simplex virus (HSV) in 22.2% (4/18) of eyes (20% of patients [3/15]). Epstein–Barr virus (EBV) was detected in 16.7% (3/18) of eyes (20% of patients [3/15]), and all the EBV-positive eyes were also positive for VZV. Polymerase chain reaction results were identical in both eyes of bilateral cases (5 patients) and were negative in 11.1% (2/18) of eyes (13.3% of patients [2/15]) biopsied. Systemic corticosteroid treatment given before ARN diagnosis did not appear to increase the risk of developing RD (P = 0.69). Rhegmatogenous RD occurred in 35.3% (6/17) of eyes given prophylactic argon laser treatment and in 80% (8/10) of eyes that could not be lasered prohylactically. Of RDs, 96.3% (13/14) occurred after the third week and up to 5 months from onset of symptoms. The VA after surgical repair of RD improved relative to the presentation acuity in 33.3% (4/12) of eyes.

Conclusion

Varicella–zoster virus is the leading cause of ARN. We recommend the management of ARN to include prompt diagnosis; prophylactic argon laser retinopexy, preferably within the first 2 weeks to reduce risk of RD; systemic acyclovir; and corticosteroids to control the severe inflammation associated with ARN. Despite the guarded visual prognosis, RD repair may result in improved visual outcomes.

Section snippets

Materials and Methods

Clinical diagnosis of ARN was based on the presence of (1) acute panuveitis, (2) occlusive retinal vasculitis (arteritis and phlebitis) with or without retinal hemorrhage, and (3) peripheral patchy necrotizing retinitis (usually multifocal) with or without retinal breaks and optic disc swelling. Other symptoms and signs when present are supportive of diagnosis: ocular or periocular pain, conjunctivitis, episcleritis, scleritis, rapid circumferential spreading and coalescence of the necrotizing

Results

There were 22 patients (12 female, 10 male). Of patients, 22.7% (5/22) had bilateral ARN; 9.1% (2/22) presented with bilateral disease at first presentation, and 13.6% (3/22) developed ARN in the fellow eye on day 14 (day 9 on acyclovir treatment), day 53 (day 53 on acyclovir treatment), and day 166 (day 110 after 56 days on acyclovir treatment), respectively, after first-eye presentation. Median age at disease onset was 51 years (49.5±3.5; range, 18–83). Mean follow-up was 4 years (range,

Discussion

Our results show that (1) VZV is the leading cause of ARN, followed by HSV (types 1 and 2); (2) all the EBV-positive eyes were also positive for VZV; (3) systemic corticosteroid treatment given before the diagnosis of ARN did not appear to correlate with the subsequent development of RD; (4) prophylactic argon laser treatment significantly reduced the risk of developing RD; (5) RD usually occurred after the third week after onset of symptoms, but there were late occurrences up to 5 months

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