Bilateral Central Retinal Artery Occlusion Associated With Herpes Simplex Virus–Associated Acute Retinal Necrosis and Meningitis: Case Report and Literature Review

Abstract

A 60-year-old woman with a history of recurrent headaches and blurred vision but otherwise healthy presented to an ophthalmologist with bilateral optic disc edema. Intravenous methylprednisonlone was administered because of a concern for optic neuritis. The patient’s vision declined to hand motions level in both eyes and a subsequent evaluation revealed bilateral acute retinal necrosis with bilateral central retinal artery occlusions. Aqueous humor polymerase chain reaction analysis was positive for herpes simplex virus (HSV), establishing a diagnosis of HSV-associated bilateral acute retinal necrosis (ARN) and meningitis. Central retinal artery occlusion (CRAO) has rarely been reported in association with ARN and the particularly fulminant course with bilateral CRAO in association with ARN has not been previously reported. Our patient’s disease course emphasizes the importance of careful peripheral examination in patients with presumptive optic neuritis, judicious use of systemic corticosteroid in this context, and the retinal vaso-obliterative findings that may be observed in the pathogenesis of ARN.

Acute retinal necrosis by herpes simplex virus type 1: an unusual presentation of a primary infection

“…The spinal tap fluid only revealed an increased lymphocyte count, with all PCR analysis negative for viral encephalitis. Brain MRI, as in several of the reports, revealed a hypersignal of the optic pathway in the T2 and Flair-weighted images 8. The diagnosis was confirmed by PCR analysis for HSV-1 of the vitreous and aqueous humour, both sterile ocular fluids.…”

“…Unilateral disease is more commonly reported in cases of ARN, nevertheless, bilateral involvement can occur in 1/3 of patients, 1–6 weeks after the first eye. Bilateral presentation of ARN is more predominant in neonates and immunosuppressed individuals than in immunocompetent patients 8. However, in our patient, none of the studies performed revealed any primary or acquired immunosuppressive disease that could justify such an aggressive evolution.…”

“…The use of corticosteroids is also controversial. In the one hand, they are very helpful in decreasing the inflammation of the ARN and associated vasculitis, but on the other hand there are some reports of corticosteroid therapy worsening the necrotising retinopathy 8 10…”

Advances in the Management of Acute Retinal Necrosis

“…Despite aggressive therapy including hospitalization for intravenous antivirals and repeated intravitreal foscarnet and ganciclovir injections, bilateral severe vision loss to hand motions level developed at final follow-up. 56 Other reports of severe cases of herpetic retinitis following corticosteroids include patients with presumptive optic neuritis, optic neuropathy, and seventh nerve palsy of unclear etiology. 57,58,59 ARN has also been described in patients treated with intravitreal triamcinolone for choroidal neovascular membranes.…”

Update on the Management of Acute Retinal Necrosis

“…Weissman et al reported a patient with suspected optic neuritis who received intravenous solumedrol and later developed bilateral central retinal artery occlusions associated with fulminant bilateral acute retinal necrosis and meningitis. 15 Some uveitis specialists have advocated local corticosteroid in the setting of cystoid macular edema after resolution of active retinitis; however, the potential for retinitis recurrence should be considered.…”