Clinical course of acute retinal necrosis (ARN) by an immunologically competent patient under combinated treatment with virustatics and pars plana vitrectomy
S. Antal, M. Lüchtenberg, O.-E. Schnaudigel, M. Zierhut, H. Gümbel
Background: The clinical picture of the acute retinal necrosis is difficult to diagnose and to treat. It concerns hardly ever immunologically competent patients and it leads in spite of antiviral therapy at 70 per cent to a retinal detachment.
Case report: With the diagnosis "Acute retinal necrosis and retinal foramina unilateral" and with progressive reduction of visual acuity on the left eye was a 28 years-old-patient transfered to our clinic. He was suspected of having CMV-retinitis.
In two clinics the young man has been treated for uveitis anterior et posterior resp. chorioretinitis and papillitis of unexplained origin with local and systemic antiinflammatory, immunosupressive and antimycotic therapy. Finally ganciclovir additionally was applied. The intravitreal infiltrations didnt increase under this therapy, however there were found defect regions of the peripheral retina. The findings of the physical examination and the nuclear spin tomography were unsuspicious.
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Within 5 weeks it came to a reduction of the visus acuity at the left eye about 80%.
On the day after the admission in our clinic the patient was operated on a pars plana vitrectomy with silicone-oil-fill and endolaser.
As active pathogen of a local infection it was a massive finding of HSV in the intravitreal punctate by PCR. Under a high dose, systemic combinated treatement with virustatics (aciclovir, brivudin) and antiinflammatory drugs the patient could be discharged at the 6th postoperative day with a visual acuity of (+7,5 sph)0,3p and a stable retina finding.
The follow-up examinations after 4 and 8 weeks showed under reduced therapy one cicatrized peripheral area of necrosis and no progression.
Conclusion: The ARN can acutely threaten the vision also of immunologically competent patients. The progessive course of the ARN can be stopped by an immediate surgical (vitrectomy) and systemic (combinated virustatic) intervention.
Universitäts-Augenkliniken, Theodor Stern-Kai 7, D-60590 Frankfurt/Main