First-line management of necrotizing herpetic retinitis by prioritizing the investigation of immune status and prognostic factors for poor visual outcomes.

PURPOSE: To review management, treatment, and outcomes of patients with necrotizing herpetic retinitis (NHR) to propose an algorithm for first-line management of NHR. METHODS: Retrospective evaluation of a series of patients with NHR at our tertiary center between 2012 and 2021 using demographic, clinical, ophthalmologic, virological, therapeutic, and prognostic characteristics was performed. Patients were classified by NHR type: acute retinal necrosis (ARN), progressive outer retinal necrosis (PORN), cytomegalovirus (CMV) retinitis. RESULTS: Forty-one patients with NHR were included: 59% with ARN, 7% with PORN, and 34% with CMV retinitis. All patients with CMV retinitis and PORN were immunocompromised versus 21% of patients with ARN. CMV infection was found in 14 (34%) patients, varicella zoster virus infection in 14 (34%) patients, herpes simplex virus type 2 infection in 8 (20%) and type 1 infection in 5 (12%) patients. Intravenous antiviral therapy was received by 98% of patients and intravitreal antiviral injections by 90% of patients. The overall complication rate during follow-up was 83% of eyes. Most frequent complications were retinal detachment (33% eyes) and retinal break (29% eyes). Prognostic factors for poor visual outcomes were pre-existing monocular vision loss in contralateral eye among 17% of patients, bilateral NHR in 17% of patients, posterior pole involvement in 46% of eyes, and involvement > 2 retinal quadrants in 46% of eyes. CONCLUSIONS: The visual prognosis of patients with NHR remains poor. Prompt investigation of immune status and presence of factors justifying intravitreal antiviral injections must be prioritized to initiate and adapt management while awaiting causative virus confirmation.

Varicella zoster virus-associated non-necrotizing retinitis: case report.

PURPOSE: To describe clinical features and the course of a case of non-necrotizing herpetic retinitis secondary to Varicella zoster virus (VZV). MATERIEL AND METHODS: A single case report documented with multimodal imaging. RESULTS: A 52-year-old female patient with a past medical history of diabetes mellitus who presented with painful red right eye (OD). Ophthalmic examination showed perilimbal conjunctival nodule, granulomatous anterior uveitis, sectoral iris atrophy and increased intraocular pressure. Fundus examination in OD revealed posterior multifocal retinitis. Left eye examination was unremarkable. Polymerase chain reaction (PCR) of aqueous humor sample confirmed the presence of VZV DNA. Systemic antiviral therapy allowed the improvement of intraocular inflammation and disappearance of the retinal non necrotizing retinitis after one year of regular follow-up. CONCLUSION: Non-necrotizing retinitis is an underdiagnosed form of VZV ocular infection.

A case of non-necrotising herpetic retinitis.

In developed countries, the main etiology of posterior uveitis is of infectious origin, Herpes is the most common viral agent as it has a wide spectral of ocular manifestations. These manifestations could depend on the patient's immunologic state, ranging from a mild focal form of non-necrotizing herpetic renitis (NNHR) to a severe form of Acute retinal necrosis (ARN). We present a case of NNHR by VHS 2 and the different differential diagnostics previous to its diagnosis: atypical ocular toxoplasmosis, ocular tuberculosis and ARN. During its evolution, it presented a drastic drop in the visual acuity despite of the antiviral treatment, and with systemic corticoids and the injury's clinical improvement. This event led to reevaluate the suspected entities, establishing the NNHR as a definitive diagnostic by exclusion that constituted a challenging diagnostic.

Case series: Two cases of herpetic retinitis presenting as progressive outer retinal necrosis in immunocompetent individuals.

PURPOSE: To raise awareness of ophthalmologists that Varicella Zoster Virus (VZV) retinitis should be considered in the differential diagnosis of retinitis that presents with features of progressive outer retinal necrosis (PORN) in healthy immunocompetent patients. OBSERVATIONS: Case 1 is a 39-year-old healthy Caucasian male who presented after one week of decreased vision in the left eye. Patient was found to have optic disc edema and multifocal retinitis primarily localized to the posterior pole with only a few lesions in the periphery and minimal vitritis. Viral PCR of a vitreous tap was positive for 1 million copies of VZV. Patient ultimately progressed to no light perception vision despite multiple intravitreal injections of foscarnet and several days of intravenous acyclovir therapy. Case 2 is another 39-year-old healthy Caucasian male that presented after 2 weeks of decreased vision in the left eye. On initial exam by his primary ophthalmologist, patient was found to have optic disc edema and multifocal retinitis primarily localized to the posterior pole with no peripheral lesions and no vitritis. The patient then presented to our clinic with extensive retinitis throughout the posterior pole and periphery, and he underwent a vitreous tap with viral PCR positive for 3160 copies of VZV. He was treated with intravitreal injections of foscarnet and intravenous acyclovir therapy with subtle progression to the right eye and only minimal improvement of left eye vision to 20/200. CONCLUSIONS AND IMPORTANCE: Progressive outer retinal necrosis (PORN) is a herpetic retinopathy characterized by rapidly progressive necrosis of the outer retina in severely immunocompromised subjects. As demonstrated in this case series, VZV retinitis should be considered as a differential diagnosis in patients with hallmark features of PORN, even in the absence of obvious systemic immunosuppression.

Electroretinogram changes in the sound eye of subjects with unilateral necrotizing herpetic retinitis.

PURPOSE: To evaluate electroretinogram (ERG) changes in the contralateral normal appearing eye of patients with unilateral acute necrotizing herpetic retinitis (NHR). METHODS: This interventional case series includes subjects with acute unilateral NHR. All patients were treated with intravenous followed by oral acyclovir and systemic steroids. Main outcome measures were changes in a- and b-wave amplitudes of scotopic and photopic full-field ERG in the sound eye, 1 and 3 months after therapy as compared to baseline. Twenty normal subjects served as controls. RESULTS: Forty eyes of 20 patients including 12 male and 8 female subjects with mean age of 44.1±11.5 (range 22 to 66) years were studied. Twenty unaffected eyes were the subject of the current study. The retina in all of these eyes remained intact during the course of the study. In the sound eyes, mean b-wave amplitude of the maximal combined response ERG before initiation of treatment was 229.5±38.8 microvolts which increased to 356.1±34.0 (P<0.001) and 365.8±32.7 (P<0.001) microvolts 1 and 3 months after treatment, respectively. Corresponding figures for b-wave amplitudes of the cone response ERG were 24.9±6.0, 47.0±12.9 (P<0.001) and 52.8±12.7 (P<0.001) microvolts, respectively. Visual acuity of all sound eyes remained unchanged throughout the study. CONCLUSION: Despite normal retinal appearance and intact visual acuity in the sound eyes of patients with NHR, electrophysiological changes were observed. Prompt diagnosis and management of NHR and continuation of medication for 3 months may reverse subclinical ERG changes and reduce the risk of progression to overt clinical disease.