ACUTE RETINAL NECROSIS Nesrine Abroug Rim Kahloun Sonia Zaouali Salim Ben Yahia Department of Ophthalmology, Fattouma Bourguiba University Hospital Faculty of Medicine, University of Monastir, Monastir, Tunisia

Ocular History 70-year-old male February 8, 2011 : vision blurring OD

Ocular History A B Fundus photograph shows a focus of active retinitis associated with retinal hemorrhages in the macular area (arrow) and associated optic disc swelling Late-phase fluorescein angiogram shows blockage effect from the area of active retinitis and dye leakage from retinal vessels and the optic disc

Initial diagnosis Non-infectious posterior uveitis Treatment with intravenous and oral corticosteroids A B

February 21 th 2011 – First Presentation Referred to our department because of worsening of visual complaints Visual acuity: OD: hand motion OS: 20/32 Mild AC inflammatory reaction OD with mutton-fat keratic precipitates and endothelial folds Intraocular pressure : 10 mmHg OD 1+ vitreous cells, 3+ vitreous haze OD OS : unremarkable

Slit-lamp photography shows granulomatous keratic precipitates and endothelial folds

Color fundus photography showing 3+ vitreous haze, extensive areas of necrotizing retinitis in the temporal and nasal periphery (arrowheads) with diffuse narrowing of retinal vessels.

Work-up PCR on aqueous humor sample identified Herpes Simplex virus-1 Syphilis serology: negative PCR on aqueous humor sample for toxoplasmosis: negative

Acute retinal necrosis Final diagnosis Acute retinal necrosis

Treatment intravenous acyclovir followed by oral antiviral therapy Oral prednisone was administrated 3 days after initiation of antiviral therapy

Follow-up Retinal detachment 3 weeks after initial presentation phacoemulsification, pars plana vitrectomy, endolaser photocoagulation, and silicone oil tamponade Retinal tear

Follow-up final visual acuity: 20/400, macular atrophy on OCT no retinitis developed in the fellow eye after a follow-up period of 12 months

Conclusion In any patient with uveitis, an infectious cause should be ruled out first Delayed diagnosis of ARN syndrome, mistakenly treated with systemic corticosteroids without coverage by antiviral therapy, may lead to significant ocular morbidity A careful clinical examination and aqueous humor analysis for PCR viral antigen provide clues for diagnosis of ARN syndrome and identification of the causative agent