J Korean Ophthalmol Soc.  2015 Jun;56(6):967-974. 10.3341/jkos.2015.56.6.967.

A Case of Progressive Outer Retinal Necrosis Treated by Combined Intravitreal Foscarnet and Ganciclovir

• Choi DY
• Lee SH
• Kim YJ
• Choi SH
• Kim EY
• Koo HH
• Kim SJ

• KMID: 2339166
• DOI: http://doi.org/10.3341/jkos.2015.56.6.967

Abstract

PURPOSE
To report a case of progressive outer retinal necrosis treated by combined intravitreal foscarnet and ganciclovir.
CASE SUMMARY
A 11-year-old male with a history of chemotherapy and cord blood transplantation due to precursor T-cell leukemia developed Herpes zoster lesion on his forehead and rapidly progressing peripheral retinal necrosis without vasculitis in the right eye. Varicella-Zoster virus was confirmed in his cerebrospinal fluid using polymerase chain reaction (PCR); and the patient was diagnosed with progressive outer retinal necrosis. Despite combined treatment with intravenous acyclovir and foscarnet and intravitreal foscarnet, retinal necrosis progressed to retinal detachment and total retinal necrosis. During follow-up, new retinal necrosis was observed in his left eye. The patient was started on combined intravenous and intravitreal foscarnet and ganciclovir; retinal necrosis in the left eye regressed and posterior pole was spared. With subsequent oral valganciclovir and intravitreal foscarnet and ganciclovir, the remaining retina was preserved with maintained vision.

Keyword

Combined intravitreal antiviral treatment; Progressive outer retinal necrosis

MeSH Terms

Acyclovir
Cerebrospinal Fluid
Child
Drug Therapy
Fetal Blood
Follow-Up Studies
Forehead
Foscarnet*
Ganciclovir*
Herpes Zoster
Herpesvirus 3, Human
Humans
Leukemia, T-Cell
Male
Necrosis*
Polymerase Chain Reaction
Retina
Retinal Detachment
Retinaldehyde*
Vasculitis
Acyclovir
Foscarnet
Ganciclovir
Retinaldehyde

Figure

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  Figure 1. (A) At initial presentation, fundus photography of the left eye shows whitish deep retinal opacification at the inferior posterior pole without vascular abnormality. Vertical OCT section shows intraretinal edema. (B) After intravenous acyclovir treatment, size of whitish retinal opaque lesion has decreased. OCT ＝ Optical Coherence Tomography.

• 

  Figure 2. (A) Under oral acyclovir treatment, new necrotic retinal lesion developed at the superior retina of the right eye. (B) After intravenous acyclovir and foscarnet treatment, confluent multiple retinal necrotic lesions developed in the peripheral retina of the right eye. (C) After additional intravitreal foscarnet injection (2,400 μ g/0.1 mL) twice a week, retinal necrosis of the right eye progressed to peripheral retinal detachment with multiple atrophic retinal breaks. (D) Whole retinal necrosis resulted after encircling, vitrectomy, silicone oil injection into the right eye.

• 

  Figure 3. (A) Photography of the left eye shows deep retinal necrosis at the inferior macula 3 months after surgery in the right eye. (B) Even after intravenous foscarnet (120 mg/kg/day), ganciclovir (10 mg/kg/day) and intravitreal foscarnet injection (2,400 μ g/0.1 mL) q48hr, peripheral retinal detachment with multiple retinal hole was developed. (C) Four months after encircling, pars plana vitrectomy, silicone oil injection in the left eye, intravenous foscarnet (120 mg/kg/day), ganciclovir (10 mg/kg/day) with intravitreal foscarnet (580 ug/0.02 mL), ganciclovir (0.2 mg/0.04 mL) twice a week was continued and retinal necrosis in the left eye was suppressed for 4 months.

• 

  Figure 4. Summary of clinical course and treatment. Dose of antiviral agents: (IV) ACV, 500 mg/m2/dose or 10 mg/kg/dose, q 8 hr; FOS, 60 mg/kg/dose, q 8 hr; GCV, 5 mg/kg/dose, q 12 hr; ACV continuous infusion, 2 mg/kg/hr; CDV, 5 mg/kg/dose, weekly (PO) VGCV, initial dose, 900 mg q 24 hr, then dose modification according to drug level monitoring (intravitreal) FOS, 2,400 μ g/ 0.1 cc or 580 μ g/0.02 cc (silicone oil filled eye); GCV, 0.2 mg/0.04 cc. Lt ＝ left eye; CSF ＝ cerebrospinal fluid; PCR ＝ polymerase chain reaction; VZV ＝ varicella zoster virus; IV ＝ intravenous; ACV ＝ acyclovir; PO ＝ per os (oral); CTx ＝ chemo-therapy; GCV ＝ ganciclovir; CMV ＝ cytomegalovirus; PORN ＝ progressive outer retinal necrosis; Rt ＝ right eye; VGCV ＝ valganciclovir; RSV ＝ respiratory syncytial virus; FOS ＝ foscarnet; CDV ＝ cidofovir.

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