Acute retinal necrosis with central retinal artery obstructi
Now open: Certificate Course in Management of Covid-19 by Govt. Of Gujarat and PlexusMDKnow more...Now open: Certificate Course in Management of Covid-19 by Govt. Of Gujarat and PlexusMDKnow more...
A 58-year-old man with diabetes, hypertension, and immunocompetence presented with diminution of vision in the right eye (RE) for 1?week. His best-corrected vision in the right eye was hand movements. Right eye anterior chamber examination revealed three positive cells with keratic precipitates. Significant vitritis with asteroid hyalosis and circumferential large retinitis lesions were noted on fundus examination. There was a cherry-red spot seen hazily at the macula suggestive of an acute central retinal artery obstruction (CRAO). His left eye examination was unremarkable. Optical coherence tomography of the right eye passing through the fovea showed the presence of hyperreflective inner layers suggestive of central retinal artery obstruction. A clinical diagnosis of right eye acute retinal necrosis (ARN) with central retinal artery obstruction was made and the patient was started on oral valacyclovir (1 g three times per day) with topical steroids. Intravitreal ganciclovir injection with anterior chamber paracentesis under topical anesthesia was advised due to the extensive retinal involvement and coexisting central retinal artery obstruction. Systemic investigations revealed non-reactive HIV with controlled blood sugars, normal complete blood counts, erythrocyte sedimentation rate, and renal function tests.

Within a week of starting therapy with oral valacyclovir and having received two intravitreal ganciclovir injections, there was a reduction in the anterior segment inflammation, vitritis and gradual resolution of retinitis. At 3 weeks, there was further improvement noted along with areas of central clearing in the superior quadrant. Simultaneous gradual resolution of cherry-red spot and retinal whitening were noted.

Acute retinal necrosis has been associated with central retinal vein occlusion, optic neuropathy, central retinal artery obstruction, and central retinal artery obstruction with cilioretinal artery sparing. Systemic association of HSV meningitis has also been described in association with bilateral acute retinal necrosis with central retinal artery obstruction. It may be prudent to note that these occlusions may develop either prior to the occurrence of retinitis lesions of acute retinal necrosis or simultaneously. Although extensive vasculitis in patients with Acute retinal necrosis has been described, the exact mechanism of the occurrence of occlusive vasculopathy with acute retinal necrosis is unclear. To conclude, in eyes with acute retinal necrosis, increased awareness of the involvement of retinal vessels, including central retinal vessels, is warranted. The involvement of central retinal vasculature in Acute retinal necrosis may lead to poor visual outcomes.