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

Abstract

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.

A Single-Center Case Series of Acute Retinal Necrosis at Teikyo University: Clinical Characteristics and Treatment Outcomes

“…This was added to the results section. In a previous meta-analysis of retrospective cohort studies on the background of ARN cases, the proportion of immunocompromised patients was as low as 21% in 24 patients with ARN, whereas it was as high as 100% in 14 cases of CMV retinitis and three cases of progressive outer retinal necrosis (PORN) [ 14 ]. Our patients were mostly healthy, except for one case (Eye No.…”

“…However, in the case of retinitis in healthy participants, there is a concern that treatment initiation may be delayed because of the time required for testing. Therefore, it has been proposed to clinically suspect ARN and intervene in the treatment of patients with retinitis without waiting for the PCR detection of viral DNA [ 14 ].…”

“…A study conducted in France that examined aqueous humor fluid or vitreous samples from 30 ARN-afflicted eyes revealed compelling findings: VZV DNA was detected in 15 eyes (50%, median age 57 years), HSV-1 DNA in seven eyes (23%, median age 47 years), HSV-2 DNA in six eyes (20%, median age 20 years), and CMV DNA in one eye (3%) [ 28 ]. Moreover, a comprehensive meta-analysis of retrospective cohort studies revealed pertinent insights: among 26 eyes afflicted with ARN, VZV infection was identified in 46% (n=12), HSV-1 in 23% (n=6), and HSV-2 in 31% (n=8) [ 14 ]. Consequently, within our present case series, a noteworthy prevalence of VZV infection superseded that of HSV infection in ARN, thus aligning with established epidemiological trends [ 14 , 21 , 28 ].…”

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

“…Herpes viruses can cause serious necrotizing conditions that affect the retina. In this context, necrotizing herpetic retinopathy (NHR) is a collective term for a group of diseases that cause acute retinal necrosis due to herpes viruses, encompassing conditions such as CMV retinitis, acute retinal necrosis (ARN), and progressive outer retinal necrosis (PORN) [55]. CMV retinitis typically occurs in immunocompromised individuals, such as those with AIDS or undergoing immunosuppressive therapy, and presents with a distinctive appearance often described as resembling "cottage cheese with ketchup", primarily affecting the posterior pole.…”

“…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].…”