Maurice F. Rabb » Acute Retinal Necrosis

On April 29, 1985, 47 year old male patient presented to the referring doctor with floaters OD, and a vision of OD 20/25 and OS 20/20 with correction. The right eye showed multiple hemorrhages and edema of the inferior temporal quadrant with A and V sheathing. The vitreous had few cells, and the disc appeared normal. The left eye showed some old punched out peripheral lesions with no activity. The tentative diagnosis of Acute Retinal Necrosis was considered and he was admitted to the University Hospital on May 10, 1985. He received 10 days of I.V. Acyclovir (500 mg. t.i.d.), Heparin, Coumadin and steroids (80 mg/day). The appearance of the eye did not change much, as was to be expected, and the patient experienced slight steroid myopathy of the thigh muscles. After discharge, he was treated with another 10 day of p.o. Acyclovir and his anticoagulants and steroids were reduced. Although the patient felt fine, the edema of the posterior pole increased with a concurrent decrease in vision (20/70 OD) and developed a marked papillitis, eventually with reduction of vision to hand movements. His workup at this time at University Hospital was entirely negative for Lues, AIDS, Toxoplasmosis, Histoplasmosis, Tuberculosis, and Sarcoidosis. His viral titres at this time showed a moderate elevation of herpes zoster, CMV, herpes simplex-I, and rubella. His toxoplasmosis titer was negative and he did have a high titer for herpes simplex-II.

When seen in our office on June 7, 1985, his history was reviewed and it was noted that he was on Prednisone 10 mg. daily p.o. His vision at that time was hand movements temporally in the right eye and 20/25+2 OS. There was a slight suggestion of a flare in the right eye, but no cells or K.P.'s were noted in the either eye. The intra-ocular pressure was within normal limits.

The diagnosis of acute retinal necrosis was sustained in the right eye with a suspicion of early onset of retinal necrosis patches in the left eye in the nasal and inferior temporal quadrants. A fluorecein angiogram was obtained which showed marked involvement of the inferotemporal vascular arcades with profuse leakage from the optic disc as well as the entire inferotemporal vascular region in the right eye. The left eye showed questionable involvement of the chorio-retinal area along the inferotemporal space with a questionable suggestion of early onset of the retinal necrosis syndrome.