J Korean Ophthalmol Soc.  2015 Mar;56(3):452-457. 10.3341/jkos.2015.56.3.452.

A Case of Atypical Acute Retinal Necrosis Observed Using Ultra-Wide-Field Imaging

• Lee HW
• Kim HC

• KMID: 2339055
• DOI: http://doi.org/10.3341/jkos.2015.56.3.452

Abstract

PURPOSE
To Report A Case Of Atypical Acute Retinal Necrosis (Arn) Observed Using Ultra-wide-field Imaging.
CASE SUMMARY
A 50-year-old male with recurrent oral ulcer presented with visual loss in his right eye. On the initial visit, slit-lamp examination showed inflammatory cells (3+) in the anterior chamber and vitreous of the right eye. Funduscopic examination and ultra-wide-field fundus images showed severe occlusive vasculitis with perivascular hemorrhage. No necrotic lesion was observed at the peripheral retina in the left eye. Under the impression of Behcet's uveitis, immunosuppressive therapies including oral steroid, intravenous cyclophosphamide, anti-tumor necrosis factor (TNF) alpha agent and intravitreal triamcinolone were administered, but without improvement. Subsequently, a necrotic lesion appeared at the far peripheral retina in the right eye and varicella-zoster virus was identified using the polymerase chain reaction test. After the patient was diagnosed with atypical ARN, intravenous acyclovir was administered, resulting in eventual suppression of the necrotic lesion progression. Due to retinal detachment, pars plana vitrectomy with silicone oil infusion was performed in the right eye. At that time, a whitish lesion at the far peripheral retina in the ultra-wide-field photography of the fellow eye was found and 3 intravitreal ganciclovir injections were administered. Finally, the whitish lesion regressed after 1 month.
CONCLUSIONS
Ultra-wide-field imaging might be useful for diagnosis and follow-up of atypical ARN patients.

Keyword

Acute retinal necrosis; Behcet's uveitis; Polymerase chain reaction; Ultra-wide-field imaging

MeSH Terms

Acyclovir
Anterior Chamber
Cyclophosphamide
Diagnosis
Ganciclovir
Hemorrhage
Herpesvirus 3, Human
Humans
Male
Middle Aged
Necrosis
Oral Ulcer
Photography
Polymerase Chain Reaction
Retina
Retinal Detachment
Retinal Necrosis Syndrome, Acute*
Silicone Oils
Triamcinolone
Uveitis
Vasculitis
Vitrectomy
Acyclovir
Cyclophosphamide
Ganciclovir
Silicone Oils
Triamcinolone

Figure

• 

  Figure 1. (A) Wide-field fundus photography of the right eye at the initial visit. Severe perivascular hemorrhages without peripheral necrotic lesion are noted. (B) Fluorescein angiography shows diffuse arteriolar and venular occlusions at the initial visit. Hyperfluorescence is observed at the nasal and temporal area (white arrow heads).

• 

  Figure 2. The progress of atypical acute retinal necrosis of the right eye. (A) On day 10, perivascular hemorrhage progressed to the optic disc. (B) On day 17, peripheral retinal necrotic lesion (white arrow heads) accompanied by retinal hemorrhage (white arrows) was first observed. Then, intravitreal acyclovir 1,000 mg (13 mg/kg) was started. (C) On the eighth day of acyclovir treatment, retinal detachment developed at the temporal area. (D) One month after vitrectomy and silicone oil infusion, the retina was well attached and remnant yellowish necrotic lesion slightly regressed.

• 

  Figure 3. Wide-field fundus photography of the left eye. (A) No remarkable lesion is found at the initial visit. (B) On day 17, whitish lesion newly appeared at 1 o’clock area in the left eye (white arrow). (C) Four days after intravitreal ganciclovir injection (2 mg/0.05 mL) and barrier laser, whitish lesion is enlarged and progressed to posterior pole (white arrow heads). Two additional intravitreal ganciclovir injections were done. (D) One month later, whitish lesion almost regressed.

Reference

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