Acute retinal necrosis

Background

• Definition:
  • Well-demarcated retinal necrosis on peripheral retina
  • Rapid progression of necrosis
  • Circumferential spread
  • Occlusive vasculopathy
  • Vitreal and aqueous inflammation
• On the spectrum of necrotizing herpetic retinopathy, with progressive outer retinal necrosis on the other end of the spectrum

Differential Diagnosis

• Most commonly HSV and VZV, though CMV also possible

Clinical Manifestations

• Starts as anterior uveitis (painful, red eye with vision loss) that progresses to retinal necrosis
• High rates of retinal detachment and blindness

Management

• Directed by causative organism
• Involvement of Ophthalmology
• Typically requires intravenous ± intravitreal acyclovir, stepped down to oral valacyclovir after 5 to 10 days, to complete 3 months
  • Sometimes intravitreal ganciclovir or foscarnet is added
• May require steroids, usually added after 24 hours of antiviral therapy
• May require vitrectomy or laser therapy

Further Reading

• Advances in the Management of Acute Retinal Necrosis. Int Ophthalmol Clin. 2015;55(3):1–13. doi: 10.1097/IIO.0000000000000077
• Acute retinal necrosis. EyeWiki. 2021. https://eyewiki.aao.org/Acute_retinal_necrosis