Kyrieleis plaques associated with Herpes Simplex Virus type 1 acute retinal necrosis

Kyrieleis plaques: recognising a rare presentation of ocular inflammation

Kyrieleis plaques are described in literature as calcific-appearing segmented inflammatory deposits along retinal arterial branches. (1) This clinical finding is most commonly unilateral and typically adjacent to an area of active retinal infection or inflammation. (2) The plaques do not appear to be intraluminal or extravasal, but rather within the vessel walls. (3) Considered to be a dishonourable eponym, this rare clinical entity is often also documented as segmental retinal periarteritis. Kyrieleis plaques are a diagnosis of exclusion and should be differentiated from other presentations of retinal vessel damage including emboli, artery sheathing, sclerosis, and periphlebitis all of which may warrant prompt referral or comanagement.

Adaptive Optics of Kyrieleis Plaques in Varicella Zoster Virus-Associated Posterior Uveitis: A Multimodal Imaging Analysis

Kyrieleis plaques (KP) represent a peculiar type of vasculitis affecting retinal arterial branches in a beaded segmental pattern that can be found in several posterior inflammatory ocular conditions. The nature and precise location of KP is unclear. Adaptive Optics (AO) provides an in vivo visualization of retinal vasculature on a microscopic level, thus permitting a more detailed characterization of KP as compared to traditional imaging techniques. This study aims to report AO imaging of KP in Varicella Zoster virus (VZV)-associated posterior uveitis and to correlate the findings with traditional imaging techniques. Three patients diagnosed with VZV posterior uveitis underwent adaptive optics (AO) imaging and traditional multimodal imaging techniques, including fundus photography, fluorescein angiography, indocyanine green angiography and optical coherence tomography. In all subjects, AO imaging revealed segmental hyporeflectivity confined to the vessel wall, with no evidence of arterial wall disruption or extravascular involvement. In our series, AO findings support the view that KP are localized within the inner arterial wall, possibly at the endothelial level.

Clinical Spectrum of Uveitis Induced by Herpes Simplex Virus with Posterior Pole Involvement at Initial Presentation: A Case Series and Literature Review

PURPOSE

To report four cases of herpes simplex virus-induced uveitis with posterior pole involvement at initial presentation.

CASE PRESENTATIONS

In case 1, the posterior pole initially showed dense vitreous hemorrhage from the optic disc, multiple subretinal lesions around the optic disc, and retinal arterial sheath prior to retinal necrosis. In case 2, the posterior pole presented with optic disc edema, retinal venous tortuosity, and arterial sheathing around the optic disc prior to the peripheral retinal necrosis. In case 3 diagnosed with posterior herpetic uveitis, the posterior pole showed retinal arterial sheath and macular structural abnormities. In case 4, the posterior pole demonstrated optic disc swelling, along with perivascular retinal hemorrhage 4 days prior to peripheral retinal necrosis.

CONCLUSIONS

Posterior pole involvement might occur either solely or before the development of peripheral retinal necrosis in patients with herpes simplex virus-induced acute retinal necrosis with and without prior central nervous system herpetic virus infection.

Kyrieleis Arteriolitis Associated with Acute Retinal Necrosis due to Herpes Simplex Virus Type 1 Secondary to Herpetic Encephalitis

We report the case of a 52-year-old woman who presented to the emergency department with acute retinal necrosis in her left eye secondary to herpes simplex virus type 1 encephalitis for which she had been hospitalized four months before. Treatment with intravitreal foscarnet and intravenous acyclovir was promptly commenced followed by the addition of oral prednisolone. PCR analysis of aqueous humor detected HSV type 1 DNA. The condition responded to therapy with partial resolution of intraocular inflammation and improvement of visual acuity, but the presence of Kyrieleis plaques was observed two weeks after the initiation of treatment, when five intravitreal foscarnet injections had been administered. The patient was switched to oral therapy with valacyclovir, and 10 weeks after commencing treatment, the patient’s left eye was free of inflammation, having achieved a BCVA of 20/20. Oral steroid treatment was gradually tapered off, and the patient was instructed to remain on prophylactic antiviral therapy. Kyrieleis arteriolitis is an uncommon finding in the context of acute retinal necrosis. As far as we are aware, we report the first case of Kyrieleis arteriolitis in acute retinal necrosis secondary to viral encephalitis and the second one presenting Kyrieleis plaques in acute retinal necrosis caused by herpes simplex virus type 1. Prior reports of cases of Kyrieleis arteriolitis in acute retinal necrosis are also presented.