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Answers: 2008 Series -  October 7, 2008 Lecture 13 of 53  NEXT»

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Figure 1
Figure 2
Photos courtesy of: Mamta Agarwal, Sankara Nethralaya, India
Used with permission. Not to be reproduced.

A 36-year-old woman came to our clinic with complaints of blurred vision and mild pain in the left eye for the last month. She was diagnosed elsewhere to have pars planitis and was treated with topical and oral steroids. She did not have any history of similar complaints in the past. There was no history of any systemic illness related to uveitis except that she suffered from chicken pox in her childhood. Her best corrected visual acuity was 6/6 in the right eye and 6/9 in the left eye. The right eye was essentially within normal limits. Slit lamp biomicroscopy in the left eye showed anterior chamber cells 1+, flare 1+ and diffuse keratic precipitates (Figure 1). Fundus examination of the left eye was as shown in the clinical photo (Figure 2).

1. What is the clinical diagnosis?

b -- acute retinal necrosis (ARN)

ARN is caused by the Herpes simplex virus, Varicella zoster virus, or rarely, cytomegalovirus. The fundus in this patient shows focal, well demarcated, yellowish white areas of retinal necrosis  in the periphery. These lesions spread circumferentially. Prominent vitreous inflammation are also seen.

2. What is the treatment?

d -- intravenous and oral acyclovir with oral steroids

Intravenous acyclovir, 1500 mg/m2 of body surface area /day intravenously is given in three divided doses for 10-14 days, followed by oral acyclovir 800 mg five times per day or oral valacyclovir 1g three times per day per day for at least 6-8 weeks from the onset of the infection . Oral steroids (40-60 mg/day) in slow tapering doses, are given 2-3 days after starting antiviral therapy.

3. Complications can be:

d -- all of the above

Rhegmatogenous retinal detachment (RRD) occurs in approximately 70% of patients due to large posterior breaks that are localized at the border between the affected and healthy retina or in the necrotic retina. Prophylaxis with laser photocoagulation is done posterior to active retinitis to prevent RRD. Secondary glaucoma develops due to endotheliitis and trabeculitis. Optic neuropathy, secondary to inflammation and ischemia of the optic nerve leads to optic atrophy.


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