Long-term follow-up of acute retinal necrosis with retinal detachment secondary to herpes simplex virus type 2 with a successful visual outcome.

A man in his early 20s presented with acute loss of vision in his only eye, the left eye (OS), and was on oral steroids. He had lost vision in his right eye during his childhood and the cause was unknown. There was no history of trauma. Best-corrected visual acuity (BCVA) in OS was 20/100 and in the right eye was hand movements. OS showed non-granulomatous keratic precipitates on the cornea, anterior chamber flare 1+ and cell 1+, early cataract, vitreous haze and cells 2+ with nasal retinal detachment and superior full thickness retinitis. He underwent pars plana vitrectomy with intravitreal ganciclovir and barrage laser away from the necrotic retina. PCR for herpes simplex virus 2 was positive from the aqueous and vitreous sample. He was started on oral valacyclovir 1 g three times a day and continued on tapering dose of oral steroids. BCVA in OS at 6-month follow-up was 20/25.

Acute retinal necrosis in a patient on immunosuppressive treatment for COVID-19 pneumonia: a case report.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) occasionally develop ocular complications. We report a case of acute retinal necrosis (ARN) caused by Epstein-Barr Virus (EBV) that developed in a patient who had severe acute respiratory syndrome due to SARS-CoV-2 infection. CASE PRESENTATION: A 68-year-old woman complained of floaters and blurred vision in her right eye as she was receiving systemic prednisolone for COVID-19 pneumonia under isolation in our hospital. The patient visited an ophthalmologist following her discharge from the hospital and after the 2 weeks of isolation had ended. At the initial examination, her best-corrected visual acuity (BCVA) was 20/100 in the right eye, and the eye showed moderate anterior segment inflammation and vitreous opacities. Treatment was initiated with topical 0.1% betamethasone and 1.5% levofloxacin. After 1 month, the inflammation in the right eye decreased and her BCVA improved to 20/40. However, on day 48 from her initial visit, the inflammation in her right eye worsened and her BCVA decreased to 20/2000 by day 80. Pars plana vitrectomy with silicone oil tamponade was performed to remove the vitreous opacities, and expanded white exudates peripherally and retinal vessels with white sheathing suggestive of acute retinal necrosis (ARN) were seen intraoperatively. Analysis of the vitreous sample revealed EBV positivity on polymerase chain reaction. The patient was diagnosed with EBV-associated ARN and treated with systemic steroids and valaciclovir. The ocular inflammation gradually decreased, and she was discharged from the hospital. However, a week later, the inflammation in the right eye markedly worsened. Despite another course of steroids, the inflammation worsened, resulting in total retinal detachment and absolute glaucoma. Because of the severe pain, the right eye was enucleated. CONCLUSIONS: Clinicians should be aware that COVID-19 and immunosuppressive treatment can reactivate EBV in the eye.

Acute Retinal Necrosis from Reactivation of Varicella Zoster Virus following BNT162b2 mRNA COVID-19 Vaccination.

PURPOSE: To report a case of acute retinal necrosis (ARN) due to varicella zoster virus (VZV) after COVID-19 vaccine administration. DESIGN/METHODS: Observational case report. RESULT: A 62-year-old immunocompetent African American male presented with left eye redness, decreased vision, and floaters after receiving a COVID-19 vaccine seven days prior. Slit-lamp examination revealed diffuse fine endothelial keratic precipitates. Funduscopic examination was notable for vitreous cells, occlusive retinal vasculitis, large retinal hemorrhages, and three quadrants of peripheral areas of retinal whitening. Quantitative polymerase chain reaction testing was positive for varicella zoster virus in the vitreous humor. Treatment with intravitreal and intravenous antiviral therapy resulted in symptomatic improvement. CONCLUSION: COVID-19 mRNA vaccination may cause an immunomodulatory response that leads to reactivation of dormant VZV. Early recognition and treatment can improve visual outcomes.

Acute Retinal Necrosis as a presenting ophthalmic manifestation in COVID 19 recovered patients.

Purpose: Infection by the SARS-CoV2 virus results in an immune dysregulated state which can predispose to reactivation of Herpes viruses. This report describes the development of Acute Retinal Necrosis (ARN) in two patients who had recovered from SARS-CoV2 infection.Methods: Observational report of two consecutive patients who presented with ARN after having recovered from SARS-CoV-2 infection.Results: Case 1 was a 5-year-old child with extensive peripheral necrotizing retinitis. Case 2 was a 61-year-old gentlemen with bilateral retinal detachment with sieve-like breaks and optic atrophy. Both patients had recovered from SARS- Cov-2 infection 1 month ago. PCR from vitreous sample of both patients was positive for Herpes simplex virus. Case 1 was treated with oral valacyclovir. Case 2 underwent surgery in both eyes for retinal detachmentConclusion: Immune dysregulation after COVID-19 infection can result in reactivation of herpesvirus and may lead to development of ARN.

Atypical bilateral acute retinal necrosis in a coronavirus disease 2019 positive immunosuppressed patient.

PURPOSE: To present the clinical features of a rare case of atypical acute retinal necrosis in a Coronavirus Disease 2019 (COVID-19) positive immunosuppressed patient. METHODS: Retrospective observational case report. RESULTS: A 75-year-old lady presented with a left eye pan uveitis picture with vitritis and extensive peripheral and mid-peripheral necrotising retinitis. In the right eye, she had a very mild superior peripheral retinitis with minimal anterior or vitreous inflammation. Two months prior to her diagnosis she completed a course of rituximab and chlorambucil chemotherapy for a relapse of diffuse large cell B-cell lymphoma (DLBCL). The patient's nasopharyngeal swabs tested positive for COVID-19 in a reverse transcription polymerase chain reaction (RT-PCR) assay. The vitreous sample PCR tested positive for Varicella Zoster Virus and was negative for SARS-CoV-2. CONCLUSION AND SIGNIFICANCE: To the best of our knowledge this is the first description of a case that has undergone vitreous PCR testing for COVID-19. It is interesting to note the high level of vitreous inflammation which would not be expected in an immunosuppressed state. We present a number of possible links between the SARS-CoV-2 virus and the unusual ocular presentation of bilateral VZV viral retinitis in this patient.While extra ocular VZV outbreaks have been reported with rituximab treated patients, this report should also raise the awareness of VZV related viral retinitis in DLBCL patients on rituximab chemotherapy which is a very rare occurrence.This case may provide some evidence to healthcare policy makers who are making decisions regarding the re-introduction of routine Ophthalmic surgery.

Varicella Zoster Virus Induced Acute Retinal Necrosis Following Acute Meningoencephalitis in a Patient with Presumed COVID-19 (preprint)

Background: To report the coincidence of acute retinal necrosis syndrome (ARN) following acute meningoencephalitis and presumed coronavirus disease 2019 (COVID-19) in an immunocompetent patient. Case presentation: A 58-year old female presented to our emergency department complaining of sudden unilateral visual loss following a recent hospitalization for a viral meningoencephalitis. Magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) analysis, polymerase chain reaction (PCR) of the aqueous humor, reverse transcriptase polymerase chain reaction (RT-PCR) of the nasopharyngeal swab specimen, chest computed tomography (CT), and fundus photography were performed for the patient. Ophthalmic examination revealed severe ocular inflammation and yellowish patches of necrotizing retinitis in the right eye compatible with the diagnosis of ARN. The result of PCR on the aqueous humor was positive for VZV. The patient received one intravitreal ganciclovir injection and 10 days intravenous ganciclovir followed by oral acyclovir. The patient underwent COVID-19 screening tests; chest CT-scan showed the features highly suggestive for COVID-19 while the RT-PCR was negative two times. Two months later, BCVA reached 20/70 in the right eye. The anterior chamber reaction and KPs resolved and the vitreous haziness significantly decreased Conclusion: A case of VZV induced ARN following acute meningoencephalitis was observed in association with presumed COVID-19. This could be an incidental finding in the pandemic era of COVID-19; however, it could also suggest that COVID-19 might trigger ARN in cases having latent herpes family viruses.