Herpes Simplex Virus Acute Retinal Necrosis during Pregnancy

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.

BILATERAL ACUTE RETINAL NECROSIS: A Case Series

PURPOSE

To investigate the clinical characteristics and visual outcome of bilateral acute retinal necrosis.

METHODS

The study included 30 patients (60 eyes) who were diagnosed with bilateral acute retinal necrosis. The medical records were reviewed.

RESULTS

Twenty-five patients developed the disease in the contralateral eye within 5 months and 5 patients at >2 years after the initial onset. At presentation, 14 of 21 eyes suffered from retinal necrosis of more than 180° in the initially affected eye, whereas 3 of 22 eyes suffered it in the later-affected eye. Retinal detachment occurred in 23 of the 27 initially affected eyes and in 5 of the 27 later-affected eyes. The mean logarithm of the minimum angle of resolution best-corrected visual acuity decreased from 2.0 ± 1.1 (Snellen equivalent counting fingers) to 2.2 ± 1.0 (Snellen equivalent counting fingers) in the initially affected eyes after a follow-up of 34.1 ± 48.2 months (P = 0.529), and improved from 0.5 ± 0.4 (Snellen equivalent 20/66) to 0.3 ± 0.4 (Snellen equivalent 20/40) in the later-affected eyes after a follow-up of 21.2 ± 23.3 months (P = 0.005).

CONCLUSION

Bilateral acute retinal necrosis usually occurs in the contralateral eye within a few months, but sometimes after several years. Inflammation and retinal necrosis are less severe in the later-affected eye, with less retinal detachment and a better visual outcome.

Diagnosis and treatment of herpes simplex 1 virus infection in pregnancy

A nulliparous woman presented at 21 weeks' gestation with a 72-h history of a rash on her left arm. Initially isolated to the forearm, it had quickly spread, becoming multiple itchy fluid-filled blisters. Blood tests showed mild neutrophilia and raised CRP. Skin swabs demonstrated the presence of herpes simplex virus type 1 (HSV1) DNA. There was no history of previous HSV1 exposure. There is scant literature on uncomplicated cutaneous HSV1 since the majority is oral/genital. The incidence of transmission varies and is dependent on site of infection and immunological status. Type-specific serological testing is recommended to identify a primary first episode infection due to the 30-60% vertical transmission rate. Infection is associated with morbidity and mortality for both mother and fetus including maternal encephalitis, acute retinal necrosis, pneumonia and hepatitis. Neonatal disease can be congenital (cutaneous lesions, microcephaly, hydranencephaly, intracranial calcifications, chorioretinitis, microphthalmia and optic nerve atrophy) or acquired (skin, eyes and mouth disease or central nervous system disease or disseminated disease). Prophylactic aciclovir reduces the number of women with active genital lesions at the time of delivery. If primary infection occurs outside of the first trimester and active genital lesions are present, then vaginal delivery should be avoided. If infection has occurred in the first trimester, vaginal birth can be attempted even in the presence of active lesions. There is no available guidance on prophylactic treatment of non-genital HSV1 in pregnancy.

Serial ultra wide field imaging for following up acute retinal necrosis cases

We describe two cases of acute retinal necrosis (ARN) in a post renal transplant diabetic patient and a pregnant female in the first trimester. Serial ultra wide field imaging (UWFI) with comprehensive ocular examination was done to monitor the progression of the disease. All the cases responded favorably with intravenous followed by oral acyclovir, which was captured with UWFI. UWFI provides objective proof of response to therapy in ARN. UWFI may also improve patient education and counseling for this peripheral retinal disorder.