Acute retinal necrosis secondary to Varicella Zoster Virus

Abstract

A 54 year old female presented to the ophthalmology clinic with pain and decreased vision in her left eye. No past medical history other than primary varicella zoster infection, in her childhood. The eye exam revealed a macular region with scattered areas of retinal opacity along with patches of necrosis on the periphery. She was started on valganciclovir and referred to the infectious disease clinic. Cell Count, blood chemistry and HIV were negative. Serum was sent for polymerase chain reaction (PCR) for Varicella Zoster Virus (VZV), Herpes Simplex Virus (HSV) and Cytomegalovirus (CMV). The VZV PCR was positive. She had decreased vision on the right eye two days later, and exam revealed peripheral retinal whitening. She was admitted and started on intravenous acyclovir. VZV is one of the most common causes of ARN and has been described in both immunocompetent and immunocompromised persons. Visual changes are usually noted weeks to months after the antecedent herpes zoster. Retinal involvement is bilateral in over half of cases, suggesting that VZV reaches the central nervous system hematogenously. The retinal exam reveals multifocal necrotizing lesions, often initially involving the peripheral retina. Therapy includes intravenous acyclovir with consideration of intravitreal foscarnet and other antivirals for progressing disease.

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“…It is recognized that ophthalmic shingles is often the inaugural disease of HIV/AIDS [4,9,10]. However, no direct link has yet been demonstrated between HIV-related immunosuppression and the 2 other pathologies due to Herpes zoster, notably keratitis and acute hypertensive anterior uveitis [4,11]. These two diseases can appear and have multiple recurrences in immunocompetent subjects.…”

“…In addition, the direct pathogenic effect of HIV has been implicated in the occurrence of a few cases of acute retinal necrosis diagnosed during this survey. It is true that herpes viruses can also be responsible for acute retinal necrosis [4,11]. The insufficiency of our laboratories has not made it possible to make a genomic diagnosis by PCR on vitreous samples.…”

From Bedside to Diagnosis: The Role of Ocular Fundus in Systemic Infections

“…Detection of CMV infection in the eye, beyond its ocular implications, signals a vital alert for possible life-threatening systemic involvement, thereby underscoring the importance of ocular assessments in comprehensive patient management, especially amidst immunosuppressive conditions [47,48]. In Table 2, principal viruses, along with their ocular fundus findings, are reported [49][50][51][52][53][54]. Herpes viruses can cause serious necrotizing conditions that affect the retina.…”

“…Treatment for PORN includes aggressive antiviral therapy administered both intravitreally and intravenously, along with the management of disease sequelae, such as retinal detachment. Despite therapy, the visual prognosis for PORN remains poor [41,51,55].…”