Rare cause of left eye floaters and blurred vision in an immunocompromised patient: acute retinal necrosis (ARN)

Abstract

Acute retinal necrosis (ARN) is a clinical syndrome featuring severe vitritis and occlusive vasculitis characterised by full thickness necrotising retinitis. ARN is usually caused by an acute infection by either varicella zoster virus or herpes simplex virus, rarely cytomegalovirus (CMV). ARN often occurs in healthy adults; occasionally affecting immunocompromised patients with poor prognosis including significant visual loss and detachment of the atrophic retina regardless of antiviral treatment. We presented a man in his early 30s with a history of left eye floaters and blurred vision. He was diagnosed with T-cell acute lymphoblastic leukaemia 1 year ago and treated with chemotherapy and allogenic haematopoietic stem cell transplant 5 months ago. His clinical diagnosis was left eye ARN caused by acute viral infection with CMV being the most likely cause, which is rarely seen in immunocompromised patients. Our case highlighted a diagnostic and therapeutic challenge in the absence of guideline or evidence-based literature to follow.

Ocular Infection of HCMV: Immunology, Pathogenesis, and Interventions

“…Although HCMV infection can occur in healthy individuals, it is uncommon to observe symptomatic infection in individuals without immune suppression [3,20]. HCMV retinitis is a clinical syndrome characterized by full-thickness necrotizing retinitis, which can result in profound vision loss, retinal detachment, and permanent vision loss [21]. The possible transmission paths of HCMV include blood, prenatal intrauterine infection, perinatal infection through breast milk or genital secretions, saliva, and sperm [22,23].…”

“…The symptoms of acute retinal necrosis include redness, ocular pain, photophobia, floaters, and blurred vision [32]. These studies suggest that the challenges in diagnosis and therapeutic challenges primarily in the absence of guidelines or evidence-based literature to follow [21].…”

“…(Tables 1 and 2). In addition to ganciclovir, given that the retina shows acute necrosis of one eye, corticosteroid or methylprednisolone is very important because of its effects in relieving intense inflammatory responses [21].…”

Diagnostic and therapeutic challenges in acute retinal necrosis; an update

“…Age is an important factor in predicting the visual prognosis, with older individuals (>80 years old) having a poorer prognosis compared to middle-aged patients [ 85 ]. The patient’s immune status should always be considered in ARN cases [ 86 ], especially in those who are immunosuppressed or immunocompromised (e.g., those undergoing biologic therapy), and a comprehensive ophthalmic assessment should be performed when visual loss is reported [ 87 – 89 ]. Although some studies have reported cases of ARN in patients with recent SARS-CoV-2 infection, further research is needed to establish a definite association [ 90 ].…”