Viral retinitis: diagnosis and management in the era of biologic immunosuppression: A review

Abstract

Necrotising retinitis is a rare ocular infection that historically led to high rates of visual morbidity. While acute retinal necrosis occurs in immunocompetent patients, the majority of cases are associated with immunocompromise such as in cytomegalovirus retinitis and progressive outer retinal necrosis. This review summarises the clinical and diagnostic features, management, and outcomes of herpetic retinitis. Iatrogenic immunosuppression is increasingly being utilised for a wide range of indications, and biologic agents especially so due to their targeted nature. While the intended actions are well‐studied, the flow‐on effects and complex interaction with host immunity are not well understood. Furthermore, biologics are frequently used concomitantly with other immunosuppressive agents, potentiating the immunodepression. This article reviews the literature on biologic immunosuppression and viral retinitis, and presents an approach to the vulnerable or affected patient. Early identification, prompt and aggressive treatment, and a multidisciplinary approach to managing immunodeficiency are the cornerstones of management.

Retrospective analysis of misdiagnosis of cytomegalovirus retinitis

“…Each patient underwent a complete medical evaluation for systemic illness, and laboratory investigations where indicated. The clinical diagnosis of CMVR primarily based on the presence of characteristic fundus findings in susceptible individuals [6]. We retrospectively analyzed eight cases that were initially misdiagnosed, seven were initially misdiagnosed as other diseases elsewhere and presented to our center at later stages of the disease, one patient presented to our center initially and misdiagnosed AS CMVR.…”

Intravitreal Methotrexate

“…While acute retinal necrosis (ARN) occurs in immunocompetent patients, progressive outer retinal necrosis (PORN) and cytomegalovirus (CMV) retinitis usually happen in immunocompromised patients. [65] The human herpesvirus family includes herpes simplex virus, varicella-zoster virus (VZV), Epstein-Barr virus (EBV), and CMV. CMV infection is the leading viral cause of visual impairment in immunocompromised patients, especially those who had undergone organ transplants.…”

Approach to Neurologic Complications in the Immunocompromised Patient

“…Diagnosis is established via dilated funduscopic exam, which can show retinal whitening, hemorrhage, and necrosis, as well as via CMV PCR of the aqueous or vitreous humor. 18,156,160 CMV has also rarely been associated with progressive outer retinal necrosis, 157,161,162 although HSV and particularly VZV infections are more often implicated in this condition. Progressive outer retinal necrosis is a rare herpetic necrotizing retinopathy characterized by multifocal peripheral opacities of the retina, progressive confluent retinal opacification, total retinal necrosis, and, often, retinal detachment.…”

“…Clinical criteria for diagnosis include retinal necrosis in the peripheral retina, rapid progression in the absence of treatment, and, by contrast to progressive outer retinal necrosis, occlusive vasculopathy and an inflammatory reaction in the vitreous and anterior chamber. 158,160 Posterior uveitis or chorioretinitis due to infection with T. gondii is typically unilateral and often seen in immunocom-petent patients, although it is also seen in the setting of immunosuppression with novel immunotherapeutics, 159 transplantation, 164 or HIV infection, sometimes with more aggressive or bilateral disease, or in tandem with cerebral toxoplasmosis. 165,166 VZV is the most common cause of progressive outer retinal necrosis and ARN; however, it may also cause ocular deficits due to multifocal VZV vasculopathy with temporal artery infection, a condition that closely mimics giant cell arteritis and causes an ischemic optic neuropathy.…”