Use of intravitreal antiviral injection during vitrectomy in the treatment of acute retinal necrosis: anatomic and visual outcomes.

PURPOSE: To investigate whether intravitreal antiviral injection (IAI) during vitrectomy reduces the postsurgical retinal detachment (RD) rate and improves the visual prognosis of patients with acute retinal necrosis (ARN). METHODS: This retrospective cohort study included ARN patients treated at a tertiary hospital between January 2013 and December 2020. Patients who underwent pars plana vitrectomy (PPV) alone or combined with intraoperative IAI were classified in PPV-only group and PPV + IAI group, respectively. The incidence of postsurgical RD and the best corrected visual acuity (BCVA) between the groups was compared. A multivariate Cox hazard analysis was employed to explore the risk factors of postsurgical RD. A multivariate logistic regression analysis was applied to assess the impact of intraoperative IAI on preventing severe vision loss (SVL). RESULTS: Fifty-seven eyes with ARN with a median follow-up of 18.5 months were included in the study. There was no significant association between intraoperative IAI during vitrectomy and a reduced risk of postsurgical RD (hazard ratio [HR], 2.65; 95% CI, 0.71-9.89) or SVL at the 6-month follow-up visit (odds ratio [OR], 0.92; 95% confidence interval [CI], 0.25-3.35). Better baseline best-corrected visual acuity (BCVA) was identified to associate with a higher risk of postsurgical RD (HR, 0.33; 95% CI, 0.14-0.81) and a lower risk of SVL at 6 months (OR, 2.28; 95% CI, 1.10-4.89). CONCLUSION: We did not observe a significant effect of intraoperative IAI on the anatomic and visual outcomes of ARN patients in this study. Intraoperative IAI may not be a necessary treatment option for ARN patients who receive vitrectomy.

Surgical Outcomes of Acute Retinal Necrosis-Related Retinal Detachment in Polymerase Chain Reaction-Positive Patients: A Single-Center Experience.

PURPOSE: To evaluate the clinical features, operative techniques, and surgical outcomes of patients who underwent surgery for acute retinal necrosis (ARN)-related retinal detachment (RD). DESIGN: Retrospective, longitudinal, consecutive case series. PARTICIPANTS: Patients with polymerase chain reaction-positive ARN presenting from 2011 to 2021 who underwent vitreoretinal surgery for ARN-related RD at our institution. METHODS: Univariate, multivariate, and survival analyses were used to determine predictors of anatomic and functional outcomes. MAIN OUTCOME MEASURES: Single-surgery anatomic success rate, recurrent RD, and visual acuity (VA) at 1 year. RESULTS: Thirty-four eyes of 34 patients (32.4% women, mean age, 45.1 ± 20.4 years) were included for analysis with a median follow-up of 2.5 years (interquartile range [IQR], 0.8-5.5 years). Presenting VA was 1.1 ± 0.8 logarithm of the minimum angle of resolution (LogMAR) (Snellen ∼20/250). The median time from presentation to RD surgery was 1.7 months (IQR, 0.8-4.1 months), and the mean preoperative VA was 1.6 ± 0.8 LogMAR (Snellen ∼20/800). Small-gauge pars plana vitrectomy (PPV) with or without a scleral buckle (SB) was performed for all eyes with an overall single-surgery success rate of 63.6%, with no statistically significant differences in visual/anatomic outcomes between PPV and PPV/SB cases. Silicone oil was used for tamponade in 33 (97.1%) cases and was removed in 10 (30.3%) with good anatomic and final functional outcomes (Snellen âˆ¼20/80). Independent predictors of recurrent RD included the female sex (hazard ratio, 8.38; 95% confidence interval, 2.03-34.68; P < 0.01) and zone 1 retinitis involvement at presentation (hazard ratio, 10.95; 95% confidence interval, 2.12-56.48; P < 0.01). The mean VA at 1 year (VA1year) and at the final follow-up both had a Snellen equivalent of 20/640 (P > 0.05 for both compared with preoperative VA, respectively). Eyes that achieved single-surgery success had VA1year of 20/200 versus hand movements in those with single-surgery failure (P < 0.01). On multivariate linear regression, younger age (P = 0.04) and better presenting VA (P < 0.01) were both associated with better VA1year. CONCLUSIONS: Moderate single-surgery anatomic success can be achieved with modern vitreoretinal surgical techniques for ARN-related RD, although visual outcomes remain poor. Further studies investigating interventions for increasing single-surgery success rates, for the inflammatory complications of ARN, and for preventing ARN-related RD are needed.

Efficacy of prophylactic laser retinopexy in acute retinal necrosis: A systematic review and meta-analysis.

PURPOSE: We performed a systematic review and meta-analysis to assess the role of prophylactic laser retinopexy in preventing rhegmatogenous retinal detachment (RRD) in acute retinal necrosis (ARN). METHODS: Pubmed, Embase and Cochrane databases were searched for eligible studies from inception to July 2020. Comprehensive clinical demographics were extracted from each study by two independent investigators. A random effects model was selected to analyze the OR of RRD risk and visual outcome with 95%CI. Subsequent subgroup and sensitivity analysis were conducted to evaluate the source of heterogeneity. RESULTS: A total of eight studies and 247 eyes (111 prophylactic laser retinopexy eyes and 136 eyes receiving antiviral treatment) were included in this analysis. There was moderate statistical heterogeneity across all studies. When compared with routine antiviral treatment alone, RRD risk decreased in patients receiving prophylactic laser retinopexy, however, this was not statistically significant (P = 0.09, OR = 0.42, 95%CI: 0.15-1.15). There was significant improvement in BCVA during the follow-up period in the prophylactic laser retinopexy subgroup (P = 0.01, WMD = - 0.98, 95%CI: - 1.74, - 0.22). CONCLUSION: Based on current analysis, our results did not support convincing evidence of prophylactic laser in preventing RRD. Future studies featuring high-quality, multicenter trials will be required to correct baseline characteristics. TRIAL REGISTRATION: This meta-analysis has been retrospectively registered in Prospero (registration number: CRD42020201008).

Therapeutic prognostic factors associated with retinal detachment and visual outcomes in acute retinal necrosis.

BACKGROUND: Acute retinal necrosis (ARN) is a fulminant necrotizing vaso-occlusive retinitis associated with a high incidence of vision loss. Prognostic factors associated with the treatment of ARN have not been comprehensively identified. This study aimed to determine therapeutic prognostic factors associated with long-term clinical outcomes in eyes with ARN. METHODS: This retrospective cohort study included patients with ARN who were treated between 2005 and 2019 in two tertiary ophthalmology departments in Seoul, Korea. Multiple logistic regression analysis was performed to investigate prognostic factors associated with late-onset retinal detachment (RD) and vision loss (<20/200). RESULTS: Sixty-one eyes with ARN with an average follow-up of 63.5 months were included. Surgical intervention of vitrectomy (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.004-0.47) and intraoperative prophylactic laser use (OR, 0.14; 95% CI, 0.02-0.81) were independently associated with a decreased risk of late RD. The factors independently associated with an increased risk of vision loss were worse initial visual acuity (OR, 3.28; 95% CI, 1.50-7.21), zone 1 involvement of necrotic retinitis (OR, 10.84; 95% CI, 1.62-72.41), and late-onset RD (OR, 5.38; 95% CI, 1.92-31.54). CONCLUSION: Vitrectomy and/or prophylactic intraoperative laser treatment may be effective treatment options in preventing delayed RD associated with an increased risk of vision loss in eyes with ARN.

Risk of Rhegmatogenous Retinal Detachment in Acute Retinal Necrosis With and Without Prophylactic Intervention.

PURPOSE: To study whether preventive laser or preventive vitrectomy is able to lower the risk of rhegmatogenous retinal detachment (RRD) in patients with acute retinal necrosis (ARN). DESIGN: A retrospective, interventional case series. METHODS: We performed a retrospective study of 59 patients (63 eyes) with ARN treated in a single tertiary referral center. We analyzed different groups with either no prophylaxis, prophylactic laser, or prophylactic vitrectomy. Main outcome measure was incidence of RRD. RESULTS: Overall incidence of RRD was 44.4%, including 13% at presentation. In a crude analysis, the risk of RRD was highest in 33 patients with prophylactic laser (45.5%), lower in 15 patients with no prophylaxis (26.7%), and lowest in 7 patients with prophylactic vitrectomy (14.3%). Baseline best-corrected visual acuity differed between these groups, but zone and percentage of involved retina did not. In a multivariable model including prophylactic laser and ARN severity, only zone was predictive of RRD. CONCLUSION: When correcting for severity of disease, we did not observe a reduction in the risk of RRD by prophylactic laser in eyes with ARN. Therefore, prophylactic laser may be abandoned. The role of prophylactic vitrectomy is still unclear, but deserves further investigation.

The necessity and optimal time for performing pars plana vitrectomy in acute retinal necrosis patients.

BACKGROUND: To compare the efficacy of pars plana vitrectomy (PPV) at different time points to treat acute retinal necrosis (ARN) and to investigate the necessity of PPV for ARN. METHODS: A retrospective review of the treatment options and outcomes of the ARN patients was performed. Thirty ARN patients (34 eyes) were included in this study. The eyes were divided into 3 groups depending on the treatment administered. In the medically treated group, there was no retinal detachment (RD) at the first visit. The routine group patients were treated with systemic antiviral medications, as well as with intravitreal antiviral injections. In the early PPV treatment group, there was no RD at the first visit. The early PPV treatment group patients were treated with systemic antiviral medications and PPV plus silicone oil tamponade and intravitreal injection. In the PPV group, there was RD at the first visit. The PPV group patients were treated with systemic antiviral medications and PPV plus silicone oil tamponade and intravitreal injection. RESULTS: In the medically treated group, the mean baseline best corrected visual acuity (BCVA) (logMAR) was 1.38 ± 0.35. The BCVA was 1.21 ± 0.36 at the last visit for the medically treated group. In this group, one eye (12.5%) developed RD after 1 month of treatment. In the early PPV treatment group, the mean BCVA (logMAR) was 1.68 ± 0.26. The BCVA was 1.83 ± 0.21 at the last visit for the early PPV group. In this group, five eyes (29.4%) had recurrent RD before silicone oil removal. In the PPV group, the mean BCVA (logMAR) was 2.0 ± 0.35. The BCVA was 1.72 ± 0.34 at the last visit for the PPV group. In this group, one eye (11.1%) had recurrent RD before silicone oil removal. There were no significant differences among the three groups in the baseline BCVA and the BCVA at the last visit (p>0.05). There were no significant differences between the early PPV group and the PPV group in the recurrent RD rates (p = 0.38). CONCLUSIONS: Prophylactic PPV showed no difference in recurrent RD rates or better BCVA. Therefore, prophylactic vitrectomy cannot prevent RD nor improve the prognosis of ARN based on our research.

Rate of Retinal Detachment after Early Prophylactic Vitrectomy for Acute Retinal Necrosis.

PURPOSE: To compare the rate of retinal detachment after acute retinal necrosis in eyes that underwent early vitrectomy versus no early vitrectomy. METHODS: Charts of patients (61 eyes) who presented to Texas Retina Associates between January 1, 2006 and December 30, 2014 for acute retinal necrosis were reviewed. Charts with incomplete documentation or follow-up less than 6 months were excluded. Twenty-nine remaining eyes were divided into two groups: early vitrectomy and no early vitrectomy. Primary outcome measure was rate of retinal detachment. RESULTS: Out of 29 eyes, 12 underwent early vitrectomy within 30 days of diagnosis and 17 either underwent vitrectomy after 30 days or did not undergo prophylactic vitrectomy at all. Three out of 12 eyes (25%) developed retinal detachment in the early vitrectomy group versus 10 out of 17 eyes (59%) in the no early vitrectomy group (p = 0.076). CONCLUSIONS: Early vitrectomy within 30 days may prevent retinal detachment after acute retinal necrosis.

Retained intraocular iron foreign body presenting with acute retinal necrosis.

We report an unusual case of retained metallic intraocular foreign body (IOFB) presenting with acute retinal necrosis (ARN). A healthy young man presented with signs of ARN including hypopyon, dense vitritis, and peripheral retinal necrosis following alleged history of trauma with a high-velocity projectile. After initial management of ARN with systemic antivirals, a retained metallic IOFB was identified and subsequently removed surgically. The patient was followed up for 12 months postoperatively and retained excellent vision without recurrence of the ARN. The diagnosis of an IOFB in a case with associated inflammation can be challenging. A strong clinical suspicion with proper investigations can achieve optimum results.

Long-Term Surgical Outcomes of Retinal Detachment Associated With Acute Retinal Necrosis.

BACKGROUND AND OBJECTIVE: To determine the long-term visual and surgical outcomes of patients with acute retinal necrosis (ARN) associated retinal detachment (RD). PATIENTS AND METHODS: The authors conducted a single-center, retrospective chart review from 2001 to 2012 of 32 eyes from 27 patients diagnosed with ARN. The authors assessed the rates and risk factors for recurrent RD in eyes having undergone primary RD repair for ARN-related RD. RESULTS: Fifteen eyes (46.9%) developed RD and 13 underwent surgical repair. Recurrent RD developed in six eyes (46.2%), occurring 35 days to 10 months after primary retinal surgery. There was no difference in the rate of recurrent RD between eyes treated with or without intravitreal foscarnet (P = .48) or initial scleral buckle (P = .31). Six eyes (46.2%) developed severe vision loss, with a final Snellen visual acuity of less than 20/200. CONCLUSION: Recurrent RD after primary repair is a frequent complication of ARN. Overall, visual prognosis is guarded despite surgical intervention. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:660-664.].

[Acute herpes simplex virus type 1 retinal necrosis three years after herpes simplex encephalitis]. / Necrosis retiniana aguda por virus herpes simple tipo 1 a los tres años de una encefalitis herpética.

TITLE: Necrosis retiniana aguda por virus herpes simple tipo 1 a los tres años de una encefalitis herpetica.

Acute retinal necrosis: factors associated with anatomic and visual outcomes.

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.

Timing of prophylactic and early vitrectomy for first-presenting or recurrent acute retinal necrosis syndrome.

Acute retinal necrosis syndrome (ARNS) is a herpetic infectious eye disease that presents clinicians with difficult decisions to make about the indication and timing of surgical intervention. Here I report 2 patients who underwent prophylactic and early vitrectomy with good visual outcomes. Case 1, a 72-year-old man, had a second recurrence of ARNS in the left eye in 2011 and underwent early vitrectomy in the acute inflammatory phase to remove previously formed vitreous opacity and vitreoretinal adhesions, in parallel with intravenous acyclovir and oral prednisolone administration. He had experienced ARNS in the right eye in 1983, in the left eye in 1986, and a recurrence in the left eye in 1999. Case 2, a 66-year-old woman, developed ARNS in the right eye. All of the circumferential retinal lesions became degenerative with intravenous acyclovir and prednisolone. She underwent a vitrectomy in the post-inflammatory phase, since epiretinal proliferation was noted through vitreous opacity with complete posterior vitreous detachment. These cases suggest that early vitrectomy in the acute inflammatory phase would be indicated for pre-existing vitreoretinal adhesions, while prophylactic vitrectomy in the post-inflammatory phase would be indicated for epiretinal proliferation.

Outcome of renal transplantation with and without intra-operative diuretics.

AIMS: This paper presents an e-survey of current clinical practice of use of intra-operative diuretics during renal transplantation in the United Kingdom and a study to compare outcome of renal transplants carried out with or without intra-operative diuretics in our centre. METHODS: An e-mail questionnaire to renal transplant surgeons exploring their practice of renal transplantation with or without intra-operative diuretics, the type of a diuretic/s if used and the relevant doses. An observational study comparing the outcome of renal transplant recipients, group no-diuretics (GND, n = 80) carried out from 2004 to 2008 versus group diuretics (GD n = 69) renal transplant recipients who received intra-operative diuretics over a one year period is presented. Outcome measures were incidence of delayed graft function and a comparison of graft survival in both groups. RESULTS: Forty surgeons answered from 18 transplant centres with a response rate of 67%. 13 surgeons do not use diuretics. Mannitol is used by 10/40, Furosemide 6/40 and 11 surgeons use a combination of both. In comparative study there was no significant overall difference in one year graft survival of GD versus GND (N = 65/69, 94% and 75/80, 94% respectively, p = 0.08) and the incidence of delayed graft function was also comparable (16/69, 23% and 21/80, 26% respectively, p = 0.07). The donor characteristics in both groups were comparable. CONCLUSION: The study showed variation in clinical practice on the use of intra-operative diuretics in renal transplantation and it did not demonstrate that the use of diuretics can improve renal graft survival.

[Pars plana vitrectomy in patients with acute retinal necrosis syndrome: surgical results in 52 patients].

PURPOSE: To analyze results of pars plana vitrectomy for acute retinal necrosis (ARN) syndrome. METHODS: We reviewed the records of 52 eyes with ARN syndrome who underwent pars plana vitrectomy at the Tokyo Medical University Hospital from 1989 to 2007. The mean age was 50.1 +/- 10.2 years and the mean follow-up duration was 75.3 months. The causative virus was herpes simplex virus in 7 cases and varicella zoster virus in 45 cases. In all cases, treatment with acyclovir and corticosteroids was started from presentation. During the follow-up period, vitrectomy was done in patients who developed retinal detachment, and in those who developed posterior vitreous detachment exerting marked traction on the retina, even though retinal detachment had not occurred. In these cases, preoperative and postoperative visual acuities were compared and reoperation, retinal detachment preventive surgery and age-stratified visual prognosis after vitrectomy were analyzed. RESULTS: Visual acuity was improved by 2 lines or more in 13 eyes (25.0%), remained unchanged in 16 eyes (30.8%), and deteriorated by 2 lines or more in 23 eyes (44.2%). Thirty-seven of 52 eyes (71.2%) required re-operation. No significant differences were detected when the patients were stratified according to whether they were treated either with or without combined use of silicon oil, or according to whether they were treated either with or without prophylactic surgery for retinal detachment, as well as by age of vitrectomy. A combination of lens extraction, silicon oil and encircling sclera buckling procedure was associated with a significantly higher frequency of final visual acuity. CONCLUSION: Despite the advances in vitrectomy achieved today, the visual prognosis of acute retinal necrosis remains unsatisfactory. The present study found no significant improvement in the prognostic relevance of prophylactic vitrectomy. Improvement in pharmacotherapy may help improve the prognosis. Further prospective large-scale studies to compare other treatment modalities are also required.

Saved by the buckle: primary buckle vitrectomy for macular hole detachment due to rapid progression of premacular fibrosis in acute retinal necrosis.

This report describes the rapid progress of a case of unilateral acute retinal necrosis (ARN) that led to formation of a macular hole rhegmatogenous retinal detachment with advanced proliferative vitreo-retinopathy (PVR) changes over the space of 2 weeks. This necessitated primary vitrectomy with circumferential scleral buckle placement, which facilitated reattachment of the retina.

Prophylactic vitrectomy for acute retinal necrosis.

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).

Acute retinal necrosis as a late sequela of herpes simplex type 1 encephalitis in a child.

Herpes simplex virus (HSV) is a common infection that occasionally presents with destructive lesions. Two of the most feared presentations of HSV are encephalitis and acute retinal necrosis. Although there are numerous reports of acute retinal necrosis presenting after HSV-2 infection in children, it has been rarely reported in children after HSV-1 infection. Herein we report a child who developed acute retinal necrosis 17 months after HSV-1 encephalitis.

Multifocal posterior necrotizing retinitis.

PURPOSE: To describe the clinical features of an acute, inflammatory, and progressive retinal necrosis that affects primarily the posterior pole. DESIGN: Retrospective, interventional case series. METHODS: Twenty-seven eyes of 24 patients diagnosed with and treated for acute retinal necrosis (ARN) were categorized into two groups according to the predominant location of retinitis at presentation: either in the peripheral retina or in the posterior pole. Clinical features, disease progression, visual outcomes, and complications of these two groups were compared. RESULTS: Fifteen eyes demonstrated the known peripheral retinitis pattern, and 12 eyes exhibited a pattern of retinitis that affected mainly the posterior pole. Eyes with peripheral retinitis showed focal, well-demarcated areas of retinal necrosis in the periphery with rapid circumferential progression and rare involvement of the posterior pole. All eyes with posterior pole retinitis had multifocal deep lesions posterior to the vortex veins at presentation, and half of these eyes had lesions in the macula. These lesions progressed to patches of confluent retinitis in both the periphery and the posterior pole. There was no significant difference between the two groups in the incidence of anterior chamber and vitreous cells, vascular sheathing, retinal hemorrhages, or optic disk edema. Patients with posterior retinitis involvement seemed to have a worse visual outcome during the first two years after diagnosis. The Cox proportional hazards model suggested a higher incidence of retinal detachment in patients with posterior retinitis (P = .07). CONCLUSIONS: The authors report a pattern of herpetic retinitis that affects predominantly the posterior pole and may have a worse visual prognosis and a higher rate of retinal detachment.