Diagnosis Of Acute Retinal Necrosis Research Articles

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

Acute retinal necrosis (ARN) was first reported in 1971 by Urayama et al as an acute uveitis accompanied by retinal arteritis and white retinal lesions in the peripheral retina that can progress to a rhegmatogenous retinal detachment (RRD). We have experienced a case of ARN that, unlike the common developmental course to an RRD associated with ARN, progressed to proliferative vitreoretinopathy (PVR) involving the entire retina in 2 days. The purpose of this report is to present our findings in the case of ARN with an atypical rapid time course. The patient was a 56-year-old woman who was treated for uveitis of unknown origin by her primary care physician. She was referred to our hospital because of a worsening of the fundus findings. Fundus examination in our hospital revealed vitreous opacities in the right eye, yellowish-white lesions extending around the retina, and some retinal hemorrhages. Because the retinal changes suggested ARN, we performed a polymerase chain reaction of the anterior atrial fluid and detected varicella-zoster virus. Then, the diagnosis of ARN was confirmed, and treatment was begun. At 1 month and a half after beginning the treatment, focal retinal traction was observed in the right fundus. Two days later, a circumferential PVR and a total retinal detachment were detected. We then performed vitrectomy with an encircling buckle and a silicone oil tamponade. Our examination 6 months postoperatively showed that the retina was attached and the BCVA was 20/200. Our findings of a case of ARN showed that the progression from a local vitreous traction to a full circumferential PVR can develop in 2 days.

Наблюдение пациентки с острым некрозом сетчатки в течение длительного периода времени

The medical and social significance of one of the most severe inflammatory diseases of the posterior segment of the eye, which includes acute retinal necrosis (ARN), is determined by the high degree of disability of patients. ARN occurs in somatically healthy people, but occurs more often among people suffering from immunosuppressive diseases or receiving immunosuppressive therapy. The diagnosis of ARN is made on the basis of clinical examination data according to the criteria developed in 1994 by the American Society of Uveitis Specialists. The prognosis of ARN is relatively unfavorable: the pathological process leads to practical blindness in 64 %, in 60 % there is a significant decrease in visual acuity. ARN is complicated by the development of retinal detachment in 65–75 %. Treatment of ARN includes intensive antiviral, anti-inflammatory, immunomodulatory therapy. Purpose: description of the observation of a patient with acute retinal necrosis over a long period of time. Material and methods. A long-term clinical observation of a patient with acute retinal necrosis for the period from 2008 to 2021 is presented. The patient underwent a standard ophthalmological examination, optical coherence tomography of the macular area, and ultrasound. Results. The development of ARN in the patient was observed after ARVI. Antiinflammatory treatment of ARN and surgical treatment of complications were carried out in the conditions of the academician S.N. Fyodorov Federal State Institution National Medical Research Center «Intersectoral Research and Technology Complex «Eye microsurgery» Ministry of Health of the Russian Federation», Novosibirsk Branch. The presented clinical case allows us to demonstrate the severe course of the pathological process and the development of serious complications. Timely conservative, laser and surgical treatment, active dynamic monitoring, despite the unfavorable prognosis for vision, made it possible to maintain residual vision in the patient. Conclusions. ARN is an important problem that requires further study and development of effective methods for early diagnosis, treatment and prevention of recurrence of this disease. Keywords: acute retinal necrosis; anti-inflammatory treatment

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

BackgroundThe present study reports the functional and anatomical outcomes of eyes with acute retinal necrosis(ARN).MethodsThis 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.ResultsTwenty-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).ConclusionsGenerally, 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.

Acute retinal necrosis caused by co-infection with multiple viruses in a natalizumab-treated patient: a case report and brief review of literature

BackgroundAcute retinal necrosis is considered a rare infectious uveitis. This condition is usually caused by varicella-zoster virus or herpes simplex virus. Acute retinal necrosis caused by co-infection with multiple viruses is extremely rare. Herein, we report a case of acute retinal necrosis caused by co-infection with herpes simplex virus (type I and II) and varicella-zoster virus (VZV) in a natalizumab-treated patient due to multiple sclerosis.Case presentationAn adult man presented with a complaint of decreased vision of the right eye from 12 days ago. He was a known case of multiple sclerosis receiving natalizumab. Examination of the right eye revealed severe conjunctival injection, fine diffuse keratic precipitates, 3 + anterior chamber and vitreous cells, elevated intraocular pressure (26 mmHg), a blurred optic disk with hemorrhagic patches, and occlusive vasculitis plus confluent necrotizing patches in the peripheral retina compatible with diagnosis of acute retinal necrosis. He underwent anterior chamber and vitreous tap, and real-time PCR detected HSV I & II and VZV on the vitreous specimen. A second PCR showed the same result. After neurological consultation, natalizumab was discontinued and intravenous acyclovir was started followed by oral acyclovir and oral prednisolone to control the disease, which was successful.ConclusionsAlthough rare, multiple-viral infection should be considered in the physiopathology of acute retinal necrosis, especially in immunosuppressed patients.

Acute Posterior Multifocal Placoid Pigment Epitheliopathy Complicated by Fatal Cerebral Vasculitis: Response.

A 21-year-old man experienced unilateral vision loss associated with multiple atrophic chorioretinal lesions. He was treated for a presumptive diagnosis of acute retinal necrosis, but his vision did not improve with antiviral therapy. Over the course of several weeks, his symptoms progressed to involve both eyes. The fellow eye showed characteristic yellow-white placoid lesions, prompting treatment with oral corticosteroids for acute posterior multifocal placoid pigment epitheliopathy (APMPPE). Despite high-dose therapy with prednisone 80 mg daily, the patient developed the acute onset of mental status changes within the next several days. Neuroimaging revealed multifocal large-vessel strokes associated with cerebral edema; these infarcts led to herniation and death. Postmortem histopathologic examination confirmed granulomatous inflammation in both ocular and cerebral vasculatures. Together with findings from multimodal imaging obtained throughout this patient's clinical course, our findings support the notion that granulomatous choroiditis is the mechanism of the ocular lesions seen in APMPPE. This granulomatous inflammation can also affect cerebral vessels, leading to strokes.

RETINAL FINDINGS IN PRESUMED INFECTIOUS POSTERIOR UVEITIS AND CORRELATION WITH POLYMERASE CHAIN REACTION RESULTS.

To correlate demographics, retinal lesion characteristics, and host immune status with the pathogen found on polymerase chain reaction analysis of aqueous fluid in patients with suspected infectious posterior uveitis. Medical records of patients who underwent anterior chamber paracentesis for suspected infectious posterior uveitis and had retinal photographs between 2014 and 2016 at a single institution were reviewed. Data collection included demographics, clinical appearance of the lesions, and polymerase chain reaction results. Fundus photographs were evaluated by two masked observers for the clinical features of the retinitis. Twenty-eight patients were included in the study. There was substantial to almost perfect agreement on retinitis location (κ = 0.67) and number (κ = 0.76) between the masked photograph graders. Polymerase chain reaction results were positive for herpes simplex virus or varicella zoster virus in 43%, cytomegalovirus in 11%, and toxoplasmosis in 3%; 43% had negative polymerase chain reaction results. Detection of herpes simplex virus or varicella zoster virus on polymerase chain reaction of the aqueous was associated with paucifocal lesions (82%, P = 0.021) and lesions involving the peripheral retina (91%, P = 0.023), consistent with the diagnosis of acute retinal necrosis. These data suggest that the diagnosis of acute retinal necrosis can be reasonably inferred on clinical examination, providing a guide for initial empiric therapy.

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

ABSTRACTPurpose: 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.

幼儿急性视网膜坏死之病例报告

目的：报告一个5岁女童罹患急性视网膜坏死之少见病例。方法：病例报告。结果：一名5岁女童因多日前突发性右眼红痛及视力模糊而求诊，病患于1岁时曾有疱疹病毒性脑炎之病史。眼科理学检查发现右眼视力为0.1，左眼为1.0。裂隙灯检查发现右眼前房及玻璃体皆有中度炎症反应，视网膜周边则出现坏死性区域。由于其典型之眼底病灶，故诊断为急性视网膜坏死，并开始给予静脉注射Acyclovir及类固醇眼药水治疗。儿科检查和实验室测试，包括免疫测试，都是正常的。十天后改为口服Valaciclovir并加上口服类固醇治疗。药效初期反应良好，三星期后视网膜坏死区域已减少，患眼视力也进步至0.3；口服类固醇逐步减量，原先之病灶于4星期后皆已消失，仅留下视网膜色素层变化，但于治疗7星期后倂发裂孔性视网膜剥离。结论：我们报告一例急性视网膜坏死发生于5岁女童之少见病例，病患经全身性抗病毒药物合倂口服类固醇治疗后一度恢复良好，但于治疗7星期后倂发裂孔性视网膜剥离。 Purpose: To report an uncommon case of acute retinal necrosis in a 5-year-old girl. Methods: Case report. Results: A 5-year-old girl presented with redness, ocular pain and blurred vision present for few days on the right eye. The past medical history revealed herpetic encephalitis at the age of 1. On examination, visual acuity was 6/60 on the right and 6/6 on the left. Slit-lamp examination showed moderate anterior uveitis and vitritis in her right eye. Fundoscopy showed large areas of peripheral circumferential retinal necrosis. Under the diagnosis of acute retinal necrosis due to its typical fundus lesions, treatment with intravenous Acyclovir and topical steroid eyedrops were started immediately. Pediatric examination and laboratory testing, including immunologic tests, were normal. After 10 days, treatment was changed to oral Valaciclovir and Prednisolone. Topical treatment was tapered gradually. The response was well initially, with resolution of retinitis patches and improvement of visual acuity to 6/20 in 3 weeks. Oral steroids were gradually reduced, and original lesions completely disappeared in 4 weeks, leaving only retinal pigment epithelial change. Seven weeks later, vision dropped to counting finger on the right due to rhegmatogeous retinal detachment. Conclusion: We report an uncommon case of acute retinal necrosis in a 5-year-old girl. This patient responded well to systemic antiviral medication and steroid initially but developed rhegmatogeous retinal detachment 7 weeks later.

Acute Retinal Necrosis: Case Report

30-year-old woman was admitted with complaints of decreased vision and pain in the left eye for the previous seven days. Visual acuity was 1.0 on the right eye and 0,2 on the left eye. Ophthalmologic examination of the left eye revealed conjunctival hyperemia, 3+ cellular reaction in the anterior chamber, diffuse keratic precipitates, 2 + cellular reaction in the vitreous. In fundoscopic examination, multiple retinal hemorrhages and foci of retinal necrosis were detected in peripheral retina with arteriolitis. The examination of the right eye was normal. The patient was admitted with the diagnosis of acute retinal necrosis and received intravenous acyclovir for ten days (10 mg/kg/day). After 48 h of antiviral therapy, systemic corticosteroid therapy (prednisolone 1 mg/kg/day) was introduced and tapered over eight weeks. Prophylactic barrier laser photocoagulation was performed in the areas of retina at the posterior borders of the necrotic lesion. During follow-up, the inflammation decreased and the patient did not have retinal detachment or other eye involvement. Acute retinal necrosis (ARN) is a syndrome with severe loss of vision and its diagnosis mostly depends on clinical appearance. ARN can be taken under control by the correct diagnosis and effective treatment. Visual prognosis can be better after the treatment and the involvement of the other eye can be prevented. Key words: Acute Retinal Necrosis; Acyclovir; Prognosis.

Acute severe visual loss and a brainstem mass

In January, 2011, a 24-year-old Afro-Colombian woman presented to us with acute decrease in vision in both eyes. Her visual acuity was 20/200 in the left eye and she could see only hand motions in the right eye. On fundoscopy she had hypopyon-associated panuveitis with large confl uent areas of retinitis (fi gure A) and ischaemic vasculitis. She complained of mild right leg pain and intermittent episodes of mild gastrointestinal discomfort in recent years. She denied a history of oral or genital ulcers, rashes, neurological defi cits, sexually transmitted diseases, gestational problems, or recent travel. A presumptive diagnosis of acute retinal necrosis was made. A vitreous sample was sent for herpesviridae PCR. Infectious disease laboratory tests were done, including HIV, HTLV 1 and HTLV 2, RPR, FTA-ABS, and toxoplasma antibodies. A Quantiferon-TB test (LabCorp, Houston, TX, USA) was positive and the IgG test for toxoplasma indicated past exposure. The rest of the physical exam ination was normal. ESR was raised (60 mm/h), and she had mild anaemia with a haemoglobin of 107 g/L. She was admitted to our hospital and given intravenous acyclovir. The next day she complained of right sided weakness, nausea, and vomiting. A neurological examination showed upper motor neuron defi cits. MRI showed an infi ltrative lesion of the pons, midbrain, and left thalamus (see appendix), consistent with lymphoma or an astrocytoma. The vitreous sample was negative for all herpesviridae, which left the diagnosis of acute retinal necrosis in doubt. Additional laboratory tests for rheumatological and demyelinating disorders, including rheumatoid factor, p-ANCA, c-ANCA, ANA, SS-A, SS-B, and serum electrophoresis were negative. A Lancet 2012; 380: 1790

Acute Retinal Necrosis Secondary to Varicella Zoster Virus in an Immunosuppressed Post-Kidney Transplant Patient

A woman, aged 42 years, presented to the ophthalmologist complaining of right eye redness, tearing, photosensitivity, and blurred vision of a 1-month duration. Her past medical history was significant for a kidney transplant for which she was immunosuppressed with mycophenolate mofetil 750 mg twice a day and prednisone 10 mg daily. Ophthalmologic examination of the right eye revealed visual acuity of 20/60, intraocular pressure of 16 mmHg, scleral injection, and a significant inflammatory reaction in the anterior chamber. Funduscopy revealed vitreous haze, optic nerve edema, arteriolar sheathing and attenuation, and peripheral 360° of retinal whitening – a clinical picture consistent with retinitis (figure 1). The left eye examination was entirely normal. Figure 1 (A) Examination of the fundus on day of presentation shows peripheral whitening and vasculitis as evidenced by optic nerve edema, vitreous haze, and retinal arteriolar narrowing. The decrease in clarity of the photograph is secondary to the vitreous haze, ... The differential diagnosis for retinitis in an immunocompromised host includes acute retinal necrosis (ARN), progressive outer retinal necrosis, cytomegalovirus (CMV) retinitis, and toxoplasmosis. Less common causes of acute retinitis include syphilis,1 Bechet's disease, and lymphoma. Aqueous fluid obtained from the anterior chamber was sent for polymerase chain reaction (PCR) viral DNA analysis, and the patient was treated with 2 mg of ganciclovir injected intravitreally on the day of presentation. A 2-week course of renal-dose adjusted intravenous (IV) acyclovir was started with subsequent regression of the retinal whitening (figure 2). Varicella zoster virus (VZV) infection with a viral load of 6.5 × 107 IU was later confirmed with PCR of the aqueous fluid. The vision initially improved to 20/40 in the right eye. She was transitioned from IV acyclovir to oral valacyclovir. Figure 2 (A) After treatment with anti-viral medication, there is regression of retinal whitening and atrophic retinal tissue. (B) Areas of regression are indicated by white asterisks. The arterioles that previously were narrowed, indicated by the white arrows, ... Seven weeks later, the patient developed a rhegmatogenous retinal detachment that was diagnosed after she complained of an abrupt decrease in vision. Despite successful surgical reattachment of the retina with pars plana vitrectomy, scleral buckle, and silicon oil, the patient's vision remained at light perception level only. Necrotizing herpetic retinopathies are caused by VZV, herpes simplex virus 1 and 2, CMV, and rarely, Epstein Barr virus. A spectrum of clinical presentations may occur depending on the virus and the host's immunity.2 Immunosuppressed patients are at risk for development of necrotizing retinopathies typically associated with immunocompromised states, such as CMV retinitis and progressive outer retinal necrosis. They may also develop syndromes that are typically seen in immunocompetent hosts, such as ARN. Acute unilateral decrease in vision, photophobia, and eye pain are the usual presentations of ARN.3 The key feature seen on examination is white-yellow, multifocal, peripheral patches that later coalesce into diffuse areas of full-thickness, peripheral retinal necrosis.4 Other signs of ocular inflammation including vitritis, vasculitis, optic disc edema, keratic precipitates, and posterior synechiae may also be seen. Untreated ARN results in blindness from retinal scarring, retinal detachment, or optic atrophy; therefore, ARN is an ophthalmic emergency. One-third of patients develop the disease in the fellow eye within one month of presentation, if left untreated.5 The diagnosis of ARN is made on the basis of clinical appearance, and antiviral treatment should be initiated promptly. Timely referral to a uveitis or retina specialist experienced in the care of such patients and collaboration with an infectious disease specialist are essential.

Kyrieleis plaques associated with acute retinal necrosis from herpes simplex virus type 2.

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. Retrospective case report. Single patient with the diagnosis of acute retinal necrosis syndrome. The patient's vitreous biopsy was positive by polymerase chain reaction for herpes simplex virus type 2. 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.

Diagnostik und Differenzialdiagnostik bei akuter retinaler Nekrose

Multiple viruses have been identified as causative agents in acute retinal necrosis (ARN). Retinal biopsies, analysis of intraocular antibody synthesis, and polymerase chain reaction (PCR) have identified varicella zoster virus, herpes simplex virus types 1 and 2, and cytomegalovirus. The differential diagnosis of ARN includes atypical ocular toxoplasmosis, some white dot syndromes, and other forms of retinal vasculitides such as Behçet's disease. Because therapeutic intervention varies greatly in these acute situations, identification of the causative agent is essential. Serology is rarely helpful, whereas analysis of aqueous humor or vitreous samples provides clues to the etiology. Aqueous humor antibody testing and PCR have demonstrated excellent diagnostic power with high sensitivity and high specificity. This review is intended to provide an overview of the diagnostics and differential diagnosis of this rare but important disorder.

Retinal Detachment in Patients with Acute Retinal Necrosis: A Case Series

Acute retinal necrosis is a rare and severe infectious ocular disease frequently complicated by retinal detachment. Records of six consecutive eyes from five patients with acute retinal necrosis were reviewed. PCR analysis of intraocular fluids was positive for Varizella zoster virus, Herpes virus 1 or 2. Treatment consisted of systemic acyclovir, systemic and local corticosteroids as well as aspirin. Progression of the necrosis could be effectively controlled, however all eyes developed retinal detachment within 55 +/- 24 days. Retinal surgery including pars plana vitrectomy, encircling scleral buckling, liquid silicone or gas filling led to retinal reattachment in all patients during the follow-up time (590 +/- 242 days). The mean visual acuity at the end of the follow-up time was 0.4 +/- 0.3. The diagnosis of acute retinal necrosis is reliably confirmed using PCR analysis of intraocular fluids. Currently available treatments are effective in stopping progression of the necrosis. There is, however, a high risk of retinal detachment, which can be successfully treated with vitreoretinal surgery.

Correlation between clinical diagnosis and PCR analysis of serum, aqueous, and vitreous samples in patients with inflammatory eye disease

To study the applicability (sensitivity, specificity) of polymerase chain reaction (PCR) tests in the detection of cytomegalovirus (CMV), herpes virus (HSV) and varicella zoster (VZV), Epstein-Barr virus (EBV), Mycobacterium sp and Toxoplasma gondii in the diagnosis of patients with or without AIDS, with presumably infectious uveitis, using serum, aqueous humor and vitreous humor samples. Twenty individuals with uveitis of presumed infectious origin were evaluated. Sixteen of them had AIDS, four were immunocompetent individuals. We also evaluated 4 normal controls who underwent vitrectomy surgery. Clinical evaluation of the patients was performed together by three clinicians. PCR evaluations of the serum, aqueous, and vitreous humor were performed in a masked fashion by the laboratory staff. Twelve patients had a clinical diagnosis of CMV retinitis. Of these 6 (50%) had a positive PCR for CMV in the vitreous, three (25%) had a positive PCR for CMV in the serum, and none were positive in the aqueous. Five patients had a clinical diagnosis of acute retinal necrosis (ARN). Three (60%) of these had positive PCR for HSV/VZV in the vitreous. One of these patients had a positive PCR reaction for both EBV and HSV/VZV in the vitreous samples. One patient with cutaneous herpes zoster had a positive PCR reaction for HSV/VZV in the serum. Four patients had a presumed diagnosis of ocular toxoplasmosis, one patient (25%) had a positive PCR for Toxoplasma gondii in the serum, 3 (75%) had positive results in the aqueous, and 2 (50%) had positive results in the vitreous. One patient with presumed ocular tuberculosis had a positive PCR reaction both in the serum and in the vitreous samples. Finally, none of the four control individuals revealed any positive PCR reaction. PCR is an auxiliary diagnostic procedure that should be evaluated together with ophthalmological aspects of the patient.

Acute Retinal Necrosis

Acute retinal necrosis (ARN) is an uncommon intraocular inflammatory syndrome characterized by severe and diffuse uveitis, retinal vasculitis, and retinal necrosis. It is typically described to occur in immunocompetent patients, but can also be found in immunocompromised subjects. Varicella-zoster virus (VZV), herpes simplex virus (HSV 1 and 2), cytomegalovirus (CMV), and Epstein-Barr virus (EBV) have been implicated in the etiology of ARN. The characteristic features of the disease include iridocyclitis, vitritis, retinal vasculitis, and retinal necrosis. Bilateral involvement occurs in two-thirds of the patients, frequently in the first six weeks, but sometimes months to years later. Retinal detachment occurs in 75% of the cases. The diagnosis of ARN is usually based in clinical features. The use of polymerase chain reaction (PCR) in aqueous humor samples is useful to identify the etiology of the disease. The treatment of ARN includes intravenous acyclovir, corticosteroids and aspirin. To prevent fellow eye involvement, intravenous acyclovir is followed by oral acyclovir for 14 weeks. Alternatives to acyclovir include ganciclovir, foscarnet, famcyclovir, brivudine, and valgancyclovir.

Acute retinal necrosis presenting with hypopyon

A 37-year-old, healthy man presented with a red, painful eye and severe anterior uveitis. Results of an extensive evaluation confirmed the diagnosis of acute retinal necrosis, and the patient underwent a diagnostic vitrectomy. The inflammation resolved with intravenous and oral acyclovir therapy. Prompt diagnosis and treatment resulted in an excellent outcome. Severe anterior uveitis with hypopyon may uncommonly be the initial manifestation of acute retinal necrosis.

Necrotizing herpetic retinopathies a spectrum of herpes virus-induced diseases determined by the immune state of the host

Purpose: Necrotizing herpetic retinopathies (NHR), a new spectrum of diseases induced by viruses of the herpes family (herpes simplex virus, varicella-zoster virus and cytomegalovirus), includes acute retinal necrosis (ARN) occurring in apparently immunocompetent patients and progressive outer retinal necrosis (PORN) described in severely immuno-compromised patients. Signs of impaired cellular immunity were seen in 16% of ARN patients in a review of 216 reported cases, indicating that immune dysfunction is not only at the origin of PORN but might also be at the origin of ARN. The aim of this study was to correlate clinical findings in NHR patients with their immunologic parameters.Methods: Charts from patients with the diagnosis of ARN or PORN seen from 1990 to 1995 were reviewed. Clinical characteristics and disease patterns were correlated with immunological parameters taking into account CD4 lymphocyte rate in AIDS patients and blood-lymphocyte subpopulation determination by flow cytometry, cutaneous delayed type hypersensitivity testing and lymphocytic proliferation rate to seven antigens in HIV-negative patients.Results: During the period considered, 11 patients and 7 patients fulfilled the criteria of ARN and PORN respectively. Immune dysfunctions were identified in most patients. Mild type of ARN and classical ARN were associated with discrete immune dysfunctions, ARN with features of PORN was seen in more immunodepressed patients and classical PORN was always seen in severely immunodepressed HIV patients.Conclusion: Our findings suggest that NHR is a continuous spectrum of diseases induced by herpes viruses, whose clinical expression depends on the immune state of the host going from mild or classical ARN at one end in patients with non-detectable or slight immune dysfunction to PORN in severely immunodepressed patients at the other end and with intermediary forms between these extremes.

Akute Retinanekrose und Herpes-Enzephalitis - Schlüsselrolle des Augenarztes bei der Diagnose opportunistischer Infektionen bei AIDS, erfolgreiche Therapie mit Acyclovir (Zovirax®)

A 43-year-old homosexual man was hospitalized in April 1988 because of acute epigastric pain. It was known that he had had a HIV infection for a year, and in April 1988 it was defined as stage Walter Reed I. Acute, exudative, nonspecific pancreatitis was diagnosed. Three weeks later cerebral symptoms (disturbances of consciousness), hypoacusis, and impaired vision developed. The ocular fundus displayed areas of edema and whitish clouding in the retina, first in the left eye and later also in the right. These were initially assumed to be anemic infarctions until the differential diagnosis of acute retinal necrosis with possible herpesvirus infection was made. On the basis of ophthalmoscopic findings cytomegalovirus retinitis appeared improbable. Serologic examinations showed increased levels of IgG antibody titers of cytomegalovirus and herpes simplex virus (both 1:20,000). Therapy with intravenous infusions of Acyclovir was instituted (1500 mg/d). After a few days the patient regained consciousness as well as his hearing and vision. There was complete resolution of the retinal exudates. This excellent therapeutic result of Acyclovir therapy confirmed the diagnosis of acute retinal necrosis syndrome, identified the cerebral symptoms as herpes encephalitis, and explained the entire disease process as the first opportunistic infection in HIV infection, i.e., by that time the patient had developed stage Walter Reed 6 (AIDS). Problems of differential diagnosis and the therapeutic schedule with Acyclovir are discussed.

Acute retinal necrosis.

Purpose: Clinical features in a case of acute retinal necrosis are described as well as its diagnostic approach and response to early treatment. Methods: This is a descriptive and retrospective study case report of a 26 year old male patient who arrived to the emergency room with a three day history of sudden visual loss in the right eye (RE). At initial evaluation a visual acuity of hand movements in the RE, 20/15 in the left eye (LE) and a right relative afferent pupillary defect were found. Fundoscopy revealed profuse soft exudates and hemorrhages involving posterior pole, inferior hemiretina and superotemporal periphery. Infectious workup and fluoresceinic angiography were made and positive serologies for herpes virus types 1 and 2, without HIV, were found. A diagnosis of acute retinal necrosis was made and treatment with intravenous valgancyclovir for two weeks and intra-vitreous triamcinolone for severe vasculitis, was given. Then a 3 months treatment with oral antiviral agents was prescribed. Results: Patient’s evolution showed improvement with treatment and at two and a half months of follow up, visual acuity was 20/50 in the right eye, normal slit lamp examination, tonometry of 12 mm Hg and fundoscopy improved when compared to initial pictures.Conclusions: A high index of suspicion is needed for diagnosing ARN taking into account clinical findings. Prompt intravenous and intra-vitreous treatments are needed to achieve good clinical and functional outcomes and to avoid central nervous system complications.