Treatment outcomes of PCR-positive acute retinal necrosis.

BACKGROUND: Acute retinal necrosis (ARN) is a progressive necrotizing retinitis caused by viral infection. Optimal management strategies have not been established for this detrimental disease. Previous literature published suggests that Varicella-zoster virus (VZV) and Herpes simplex virus-1 (HSV1) are the most common promoters of acute retinal necrosis (ARN). AIMS: The purpose of our study was to investigate the viral distribution, demographic, and treatment outcomes of ARN. METHODS: A retrospective chart review evaluated data from PCR-positive ARN patients diagnosed between 2009 and 2018. RESULTS: Analysis of fourteen eyes from 12 patients found CMV and VZV as the commonest causes of ARN. Patients on 1 g of valacyclovir three times a day (V1T) had worse vision between first and final visits (mean difference of 1.25 ± 0.65, n = 2) compared with patients treated with 2 g of valacyclovir three times a day (V2T), or 900 mg twice a day of valganciclovir (V9B) (mean difference of - 0.067 ± 0.13, n = 6, and 0.067 ± 0.067, n = 6, respectively). Both V1T patients developed retinal detachments (RD). Both CMV patients treated with intravitreal triamcinolone developed ARN, elevated IOP, and one developed multiple RD. CONCLUSIONS: Our review found increased incidence of CMV-positive ARN. Patients with zone 1 disease had worse initial visual acuity. Moreover, patients had more favorable outcomes with V2T and V9B compared to V1T. CMV-positive patients clinically worsened after intravitreal steroid injections, further underscoring the value of a PCR diagnosis to tailor the patients' treatment plan accordingly.

Acute Retinal Necrosis: A Covid-19 Perspective.

Acute retinal necrosis (ARN) is a relatively uncommon yet devastating cause of vision-threatening uveitis. This manuscript analyzed the cases of ARN that have been reported following SARS-CoV-2 infections and anti- SARS-CoV-2 vaccinations. A total of nine cases of ARN were reported in the literature. Among them, four patients with ARN were attributed to SARS-CoV-2 infections, and a history of recent Covid vaccination was present in five patients when a diagnosis of ARN was made. ARN has been described following SARS-CoV-2 infections or vaccinations against the virus, and many of these cases may be based on a cause-to-effect hypothesis.

A Case of Acute Retinal Necrosis Associated with Reactivation of Varicella Zoster Virus after COVID-19 Vaccination.

PURPOSE: To report a case of acute retinal necrosis (ARN) after receiving COVID-19 vaccination. METHODS: A case report. RESULTS: A 78-year-old man complained of blurred vision and floaters in the right eye 2 days after receiving BNT162b2 mRNA-based COVID-19 vaccine and was referred to our hospital with worsening visual acuity after 7 days. He had no systemic symptoms and no history of systemic diseases. Ophthalmic examination revealed white-yellowish placoid lesions spreading to the entire circumference of the retina, and temporal and upper lesions extending to the posterior pole, although anterior inflammation and vitreous opacity were mild. Diagnostic and therapeutic vitrectomy was performed, and VZV-DNA was detected by comprehensive PCR using a vitreous fluid sample. The ocular inflammation subsided by systemic administration of antivirals and corticosteroids. However, total retinal detachment requiring repeat vitrectomy using silicone oil occurred after the second vaccination. CONCLUSION: ARN associated with VZV reactivation may develop after SARS-CoV-2 mRNA vaccination.

Reactivation of varicella zoster infection presenting as acute retinal necrosis post COVID 19 vaccination in an Asian Indian male.

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.

Varicella Zoster Reactivation Causing Acute Retinal Necrosis following mRNA COVID-19 Vaccination in a Young Immunocompetent Man.

BACKGROUND: Varicella zoster reactivation is an increasingly recognised event following mRNA COVID-19 vaccination. In addition, various ocular inflammatory and infectious adverse events following COVID-19 vaccination have been described in the literature. This case report describes acute retinal necrosis (ARN) secondary to varicella zoster virus (VZV) reactivation following COVID-19 mRNA vaccination. CASE DESCRIPTION: A 42-year-old immunocompetent man developed left ARN 12 days following first dose of Pfizer BioNTech mRNA COVID-19 vaccination. Aqueous and vitreous tap polymerase chain reaction testing was positive for VZV. Good visual outcome was achieved with combination therapy, including intravitreal foscarnet, oral valaciclovir and prednisolone, topical dexamethasone and atropine, and barrier retinal laser. Second dose of the vaccine is planned under cover of high-dose oral valaciclovir therapy. CONCLUSION: This case illustrates the possible association between COVID-19 vaccination and potentially blinding VZV reactivation. Therefore, prompt ophthalmic assessment is recommended in patients with visual disturbance following COVID-19 vaccination.

Case Report: Acute Retinal Necrosis after a Cervical Epidural Steroid Injection.

SIGNIFICANCE: Acute retinal necrosis is a rare, sight-threatening condition typically found in immunocompromised patients and is most commonly caused by varicella zoster virus. Because of the poor prognosis and rapid progression of the disease course, prompt antiviral management is paramount. PURPOSE: A case report of acute retinal necrosis in a patient with herpes virus infection after a cervical epidural corticosteroid injection was performed. Extensive laboratory work and frequent follow-ups are necessary for management. This case report outlines the clinical signs of acute retinal necrosis and discusses the appropriate referrals and treatment needed to improve prognosis. CASE REPORT: A 63-year-old man presented to our eye clinic with symptoms of pain and light sensitivity. Examination revealed anterior uveitis, vitritis, optic disc edema, macular edema, vasculitis, and retinitis of the left eye. The serum antibody test results showed abnormal ranges for varicella zoster virus and herpes simplex virus type 1, and the patient was diagnosed with acute retinal necrosis. Treatment prescribed by a retina specialist included oral valacyclovir and later oral prednisolone, for which the patient responded well before developing the common complication of retinal detachment. CONCLUSIONS: The progressive nature of acute retinal necrosis is usually debilitating to vision, even when managed properly. Because prognosis is often poor, it is important to make proper diagnoses combined with a complete review of the patient's medical history and immune status to prevent further vision loss.

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).

Clinical Features of Acute Retinal Necrosis with Optic Neuropathy and Central Retinal Artery Occlusion as Initial Manifestations.

Acute retinal necrosis normally occurs at the periphery retina and gradually merges and progresses to the posterior pole. Optic neuropathy and central retinal artery occlusion as initial manifestation is very rare. We report the case of a patient with optic neuropathy and central retinal vessels as the first manifestations of acute retinal necrosis. Antiviral drugs, corticosteroids, and drugs that improve blood circulation were given. The necrotic retina and swollen optic disc disappeared gradually. However, the final vision of this eye declined to no light perception. From the first case report in 2001 to now, a total of 8 sporadic cases have been reported. The average onset age is 60.85±14.05 years. Most of them had no history of virus infection. Cardiovascular disease history maybe a risk factor. Acute retinal necrosis should be considered in patients with retinal vascular occlusion accompanied by granulomatous anterior uveitis. Further research is needed to determine whether treatments in addition to antiviral and corticosteroid therapy are needed.

Acute Retinal Necrosis as a presenting ophthalmic manifestation in COVID 19 recovered patients.

Purpose: Infection by the SARS-CoV2 virus results in an immune dysregulated state which can predispose to reactivation of Herpes viruses. This report describes the development of Acute Retinal Necrosis (ARN) in two patients who had recovered from SARS-CoV2 infection.Methods: Observational report of two consecutive patients who presented with ARN after having recovered from SARS-CoV-2 infection.Results: Case 1 was a 5-year-old child with extensive peripheral necrotizing retinitis. Case 2 was a 61-year-old gentlemen with bilateral retinal detachment with sieve-like breaks and optic atrophy. Both patients had recovered from SARS- Cov-2 infection 1 month ago. PCR from vitreous sample of both patients was positive for Herpes simplex virus. Case 1 was treated with oral valacyclovir. Case 2 underwent surgery in both eyes for retinal detachmentConclusion: Immune dysregulation after COVID-19 infection can result in reactivation of herpesvirus and may lead to development of ARN.

ACUTE RETINAL NECROSIS AND CONTRALATERAL CUTANEOUS ERUPTION AFTER THE SHINGLES VACCINE.

PURPOSE: To the best of our knowledge, we present a rare case report describing an occurrence of acute retinal necrosis in an otherwise healthy individual who received the shingles vaccine. METHODS: Observational case report. PATIENT: A 63-year-old healthy and immunocompetent white man presented with change of vision in the left eye after blunt trauma. A diagnosis of corneal abrasion was made. During follow-up, a detailed history discovered a progressive deterioration in vision over the past few weeks. Three months before presentation, he had received the shingles vaccine (Zostavax); 1 month before presentation, he reported an episode of varicella skin eruption on the face. RESULTS: On examination, the patient was found to have acute retinal necrosis with white satellite lesions in the fundus of the left eye. An anterior chamber paracentesis and polymerase chain reaction confirmed the diagnosis of varicella-zoster virus. CONCLUSION: Varicella-zoster virus reactivation after shingles vaccination may predispose both immunocompetent and immunocompromised individuals to herpes-zoster ophthalmicus, leading to acute retinal necrosis.

Outcomes of Combination Systemic and Intravitreal Antiviral Therapy for Acute Retinal Necrosis.

PURPOSE: Determine the efficacy of combination intravitreal and systemic antiviral therapy for the treatment of acute retinal necrosis (ARN) and risk factors impacting visual acuity (VA) and retinal detachment (RD) outcomes. DESIGN: Single-center retrospective case series. PARTICIPANTS: Patients with an ARN diagnosis based on clinical features and polymerase chain reaction confirmation who were treated at a tertiary referral, university-based academic practice. METHODS: Patient records were reviewed for demographic information including age and gender. Snellen VA, disease findings including RD outcomes, optic nerve involvement, and treatments were recorded. Incidence rates of major VA and RD outcomes were calculated based on the number of events and exposure times. Cox proportional hazards regression modeling and survival analyses were used to identify factors related to VA and RD outcomes over time. MAIN OUTCOME MEASURES: Logarithm of the minimal angle of resolution VA, 2-line or more VA gain, severe vision loss (SVL) of 20/200 or worse, RD development, and fellow eye involvement. RESULTS: Twenty-three eyes of 21 patients (11 male, 10 female) were reviewed. Thirteen patients (62%) had herpes simplex virus and 8 patients (38%) had varicella zoster virus. The event rate for 2-line or more VA gain was 0.49 events/eye-year (95% confidence interval [CI], 0.26-0.86 events/eye-year), whereas the rate of SVL was 0.61 events/eye-year (95% CI, 0.34-1.02 events/eye-year). Retinal detachment development was observed at a rate of 0.59 events/eye-year (95% CI, 0.33-1.00 events/eye-year). Thirteen of 23 eyes (57%) demonstrated RD with a mean time of 120 days after ARN diagnosis. With each additional quadrant of retina involved, a greater risk of RD development over time was observed (hazard ratio, 2.21; 95% CI, 1.12-4.35). Nine percent of eyes progressed with additional quadrantic involvement, despite combination systemic and intravitreal antiviral therapy; however, none of the 19 patients demonstrating unilateral ARN showed fellow-eye involvement after initiation of therapy. CONCLUSIONS: Combination intravitreal and systemic antiviral therapy for ARN can be effective in improving VA and limiting retinitis progression. Each additional quadrant of retina involved was associated with a 2.2-fold greater risk of RD, which may impact monitoring, timing of intervention, and patient counseling.

[Acute retinal necrosis caused by varicella zoster virus]. / Ostryi nekroz setchatki, vyzvannyi virusom opoyasyvayushchego gerpesa.

Incidence of Herpes Zoster is relatively high. Herpes zoster ophthalmicus is one of the most common forms of the disease. Necrotising herpetic retinopathies (including acute retinal necrosis) are rare and usually these complications are presented in literature as individual cases. However, necrotising herpetic retinopathy can lead to complete loss of visual. The article reviews modern data on causation, diagnosis and treatment of acute retinal necrosis analyzing 40 open access articles from EBSCO published in 2011-2019, and describes the modern views on the prevalence and most important clinical features of herpetic acute retinal necrosis. Some contradictory opinions have been revealed concerning the diagnostic criteria and surgical treatment of acute retinal necrosis.

Bilateral acute retinal necrosis in premature newborn with skin, eye, and mouth infection presenting with vitreous and subretinal hemorrhage.

A premature newborn with systemic sepsis due to Candida albicans and parapsilosis developed skin, eye, and mouth herpetic infection. Ocular disease presented atypically with vitritis and pre and subretinal hemorrhage due to herpes simplex virus-1 confirmed fulminant bilateral acute retinal necrosis. Pars plana vitrectomy revealed necrotizing retinitis with poor visual prognosis. The baby has survived suffering from multiple morbidities which include post-hemorrhagic hydrocephalus, chronic lung disease, patent ductus arteriosus, and developmental delay.

Visual outcome and poor prognostic factors in acute retinal necrosis syndrome.

OBJECTIVE: To evaluate the impact of selected clinical parameters on the mid-/long-term visual outcome of patients with acute retinal necrosis (ARN) DESIGN: A retrospective cohort study SETTING: Two University Hospitals (Parma, Italy; Lausanne, Switzerland). PARTICIPANTS: Thirty-nine non-HIV patients (39 eyes) with ARN, as confirmed by polymerase chain reaction on intraocular samples. The following potential predictors were tested using linear regression models: age, sex, etiology, best-corrected visual acuity (BCVA) on admission, delay between ARN symptom onset and treatment initiation, and surgery (performed or not). MAIN OUTCOME: BCVA at the final follow up RESULTS: Thirty-nine of 39 non-HIV patients (22 men and 17 women; mean age, 50 years) diagnosed with ARN were enrolled in the study. Etiologies were: varicella-zoster virus in 25 eyes (64%), herpes simplex viruses in the remaining 14 eyes. The average follow-up duration was 19 ± 13 months. All patients had undergone systemic antivirals; surgery was performed in 16 eyes. The mean delay between onset of visual symptoms and antiviral treatment initiation was 15 ± 31 days (range, 1-180 days). The mean BCVA at baseline was 0.83 ± 0.75 logMAR, while the mean final BCVA was 0.75 ± 0.81 logMAR. Both initial BCVA and treatment delay (TD) were significantly correlated with the final BCVA (p < 0.05). CONCLUSIONS: Initial BCVA and TD seem to be significant predictors of mid-/long-term visual outcome in non-HIV patients affected by ARN.

Development of Acute Retinal Necrosis in a Patient with Ocular Sarcoidosis: A Case Report.

Purpose: To report a case of acute retinal necrosis (ARN) caused by varicella-zoster virus (VZV) in an elderly patient with ocular sarcoidosis after oral corticosteroid indication. Methods: Retrospective case report. Results: A 75-year-old male with a past history of ocular sarcoidosis came with blurred left vision. Ocular findings in the left eye were consistent with ocular sarcoidosis, while no inflammation in the right eye. On day 14, intraocular inflammation in the left eye resolved by topical corticosteroid, but inflammatory cells were found in the right eye. Suspecting recurrence of ocular sarcoidosis, systemic corticosteroid was initiated. On day 21, inflammation worsened, and the presence of extended yellowish white peripheral retinal lesion in the right eye suggested ARN. Polymerase chain reaction (PCR) testing using ocular fluid detected 3.0 × 107 copies/ml of VZV DNA. Conclusions: In the case of poor response to immunosuppressive therapy in elderly uveitis, infection including ARN should be considered. Immediate PCR testing for pathogen screening is required.

Acute retinal necrosis following herpes simplex encephalitis: a nationwide survey in Japan.

PURPOSE: Acute retinal necrosis (ARN) is a severe necrotizing retinitis caused by varicella-zoster virus or herpes simplex virus (HSV) that often results in blindness. Occasionally, HSV-caused ARN develops after herpes simplex encephalitis (HSE). It remains unknown, however, when and how often ARN develops after HSE. To investigate the actual conditions of patients with ARN following HSE and the interval period between the prior HSE and the onset of ARN, a retrospective nationwide survey of the Japanese population was performed. STUDY DESIGN: Retrospective. METHODS: Questionnaires were sent out to the neurology and ophthalmology departments of teaching hospitals in Japan. They inquired about HSE patients in neurology departments and ARN patients diagnosed with HSV in ophthalmology departments. The proportion of the HSV-ARN patients with a history of HSE and their interval periods were obtained from the questionnaires returned by the ophthalmology departments. RESULTS: Neurology departments of 324 hospitals responded to the questionnaires (response proportion: 40.9%), and 53 HSE cases were reported. Ophthalmology departments of 535 hospitals responded the questionnaires (response proportion: 54.3%), and 67 HSV-ARN cases were reported. Among the 67 HSV-ARN cases, 16 (23.9%) had histories of prior HSE. Although the interval periods from the prior HSE to the onset of HSV-ARN varied among cases, nearly half developed HSV-ARN within 2 years. CONCLUSIONS: This nationwide survey of the Japanese population showed that HSV-ARN develops after HSE in higher frequency within 2 years. Neurologists and ophthalmologists should be aware that HSE survivors have a risk of contracting HSV-ARN.

Acute retinal necrosis in a patient with remote severe herpes simplex encephalitis.

A 60-year-old man with a history of severe herpes simplex virus type 1 (HSV-1) encephalitis 2 years prior presented with acute onset of visual loss in the left eye. Dilated funduscopic examination showed retinitis and occlusive vasculitis with retinal necrosis. PCR of the vitreous fluid was positive for HSV-1, and he was diagnosed with acute retinal necrosis (ARN) due to HSV-1. The patient was treated with intravenous acyclovir and intravitreous foscarnet for 2 weeks, followed by high dose oral valacyclovir for 2 weeks. He was subsequently placed on planned life-long suppressive valacyclovir. His case demonstrates that acute visual loss concomitant with or subsequent to HSV-1 encephalitis warrants suspicion of ARN. Prompt therapy with effective antiviral medication is necessary to reduce the risk of sight-threatening complications. Chronic suppression with oral antiviral therapy after ARN is recommended to prevent involvement of the contralateral eye, though there is no consensus on the duration and dosage of antivirals.