1. 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

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

3. 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

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

5. 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

6. Slit-lamp photography shows granulomatous keratic precipitates and endothelial folds

7. 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.

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

9. Acute retinal necrosis
Final diagnosis
Acute retinal necrosis

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

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

12. 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

13. 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