Acute Retinal Necrosis Presenting With Optic Disc Edema

Optic disc edema, a potential complication of acute retinal necrosis (ARN), usually develops concurrently or after the development of retinal abnormalities. In the few reported cases of ARN with optic disc edema, retinal involvement and uveitis were evident as well. We describe a patient with ARN initially presenting with only optic disc edema and with no other signs of ARN, mimicking nonarteritic anterior ischemic optic neuropathy (NAION).

Clinical Correspondence Acute Retinal Necrosis Presenting With Optic Disc Edema Yong-Il Shin, MD, Ju-Mi Kim, MD, Jung-Yeul Kim, MD, PhD, Yeon-Hee Lee, MD, PhD O ptic disc edema, a potential complication of acute retinal necrosis (ARN), usually develops concurrently or after the development of retinal abnormalities. In the few reported cases of ARN with optic disc edema, retinal involvement and uveitis were evident as well. We describe a patient with ARN initially presenting with only optic disc edema and with no other signs of ARN, mimicking nonarteritic anterior ischemic optic neuropathy (NAION). A 59-year-old woman reported a 3-day history of painless blurred vision in her left eye. Her general health was excellent, and she was taking no medications. Visual acuity was 20/20 in both eyes, and there was a left relative afferent pupillary defect. Color vision was intact. Slit-lamp examination was normal. The right fundus appeared normal. The left fundus also was unremarkable, except for left optic disc edema (Fig. 1). Automated visual field testing was normal in the right eye and showed a superior arcuate defect in the left eye. Orbital MRI was normal. A presumptive diagnosis of NAION was made, and prednisolone (40 mg) with low-dose aspirin was prescribed. Ten days later, the patient had marked decreased vision in both eyes, with acuity of 20/2,000, right eye, and 20/800, left eye. The anterior chamber showed trace cells in the right eye and 2+ cells in the left eye. Fundus examination demonstrated optic disc edema in the right eye and advanced optic disc swelling and peripheral retinal necrosis in the left eye (Fig. 2). The right retina had no peripheral abnormalities, which was confirmed on FIG. 1. At initial visit, the right fundus appears normal, whereas in the left eye, there is optic disc edema with an interior splinter hemorrhage. Department of Ophthalmology, Chungnam National University College of Medicine, Daejeon, Republic of Korea. The authors report no conflicts of interest. Address correspondence to Yeon-Hee Lee, MD, PhD, Department of Ophthalmology, Chungnam National University Hospital, #282 Munhwa-ro, Jung-gu, Daejeon 35015, Republic of Korea; E-mail: [e-mail] Shin et al: J Neuro-Ophthalmol 2019; 39: 105-106 fluorescein angiography. A diagnosis of ARN was made, and the patient was treated with intravenous acyclovir, intravitreal ganciclovir, aspirin, and topical and oral steroids after 48 hours of intravenous acyclovir. A polymerase chain reaction of a vitreous sample showed the presence of herpes simplex virus 1. 105 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Clinical Correspondence FIG. 2. Ten days after initial evaluation, the right optic disc is swollen (A), and the left fundus reveals advanced optic disc swelling and peripheral retinal necrosis (B). Two weeks later, the patient's visual acuity was 20/50 bilaterally. Optic disc swelling had subsided in both eyes, and the extent of necrotic retina in the left eye had decreased. Five weeks after treatment, pars plana vitrectomy and silicone oil injection were performed in the left eye for rhegmatogenous retinal detachment. Six months later, visual acuity was 20/50, right eye, and counting fingers, left eye. Both optic discs were pale. ARN is usually diagnosed on a clinical basis and initially accompanied by anterior uveitis, complaints of ocular discomfort, conjunctival hyperemia, periorbital pain, and floaters. Retinitis appears as multifocal, yellow-white patches, typically beginning in the peripheral retina. Vasculitis occurs in the form of vascular sheathing and perivascular retinal hemorrhage. In the acute phase, optic disc edema occurs due to intraocular inflammation or ischemic changes, which results in sudden and severe visual impairment and later optic atrophy. Optic nerve involvement usually develops after, or simultaneous with, retinal necrosis (1). Optic neuropathy that precedes retinal involvement is a rare presentation in ARN but has been reported in immunocompromised patients (2,3). In immunocompetent patients, optic nerve involvement has been reported with panuveitis or moderate anterior uveitis, without evidence of retinal necrosis (4-6). We are unaware of any reports of isolated optic disc edema as the sole initial manifestation of ARN. But we agree with Koh et al (7) that in any patient presenting with optic disc edema, a complete ophthalmic examination is essential to exclude findings of concurrent inflammation in both the anterior and posterior segments of the eye. 106 STATEMENT OF AUTHORSHIP Category 1: a. Conception and design: Y.-H. Lee and J.-Y. Kim; b. Acquisition of data: Y.-I. Shin and J.-M. Kim; c. Analysis and interpretation of data: Y.-I. Shin and J.-M. Kim. Category 2: a. Drafting the manuscript: Y.-I. Shin, J.-M. Kim, and Y.-H. Lee; b. Revising it for intellectual content: J.-Y. Kim and Y.-H. Lee. Category 3: a. Final approval of the completed manuscript: Y.-I. Shin, J.-M. Kim, J.-Y. Kim, and Y.-H. Lee. REFERENCES 1. Witmer MT, Pavan PR, Fouraker BD, Levy-Clarke GA. Acute retinal necrosis associated optic neuropathy. Acta Ophthalmol. 2011;89:599-607. 2. Meenken C, van Den Horn GJ, de Smet MD, van Der Meer J. Optic neuritis heralding varicella zoster virus retinitis in a patient with acquired immunodeficiency syndrome. Ann Neurol. 1998;43:534-536. 3. Friedlander SM, Rahhal FM, Ericson L, Arevalo JF, Hughes JD, Levi L, Wiley CA, Graham EM, Freeman WR. Optic neuropathy preceding acute retinal necrosis in acquired immunodeficiency syndrome. Arch Ophthalmol. 1996;114:1481-1485. 4. Tornerup NR, Fomsgaard A, Nielsen NV. HSV-1-induced acute retinal necrosis syndrome presenting with severe inflammatory orbitopathy, proptosis, and optic nerve involvement. Ophthalmology. 2000;107:397-401. 5. Kojima M, Kimura H, Yodoi Y, Matsunaga N, Ogura Y. Preceding of optic nerve involvement in acute retinal necrosis. Retina. 2004;24:297-299. 6. Francis PJ, Jackson H, Stanford MR, Graham EM. Inflammatory optic neuropathy as the presenting feature of herpes simplex acute retinal necrosis. Br J Ophthalmol. 2003;87:512-514. 7. Koh YT, Ang BC, Ho SL, Beng Teoh SC, Agrawal R. Herpes simplex acute retinal necrosis presenting as unilateral disc swelling in young immunocompetent patients. Ocul Immunol Inflamm. 2017;25:797-801. Shin et al: J Neuro-Ophthalmol 2019; 39: 105-106 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.