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E. Baglivo, E. Oueghlani, O. Durakovic, H. Roux, A. Safran; Varicella–zoster Virus Retinitis: Successful Evolution With a Combination of Antiviral Therapies . Invest. Ophthalmol. Vis. Sci. 2005;46(13):1041.
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© ARVO (1962-2015); The Authors (2016-present)
Purpose: Acute retinal necrosis (ARN) is an infectious disease responsible for severe ocular morbidity and permanent visual impairment in immunocompetent patients. The diagnosis is based on clinical fundoscopic features represented by areas of retinal necrosis. Most cases are caused by varicella–zoster virus (VZV), herpes simplex virus types 1 and 2 (HSV–1, HSV–2) and more rarely by Epstein–virus (EBV). We report 2 cases of severe ARN resistant to an acyclovir monotherapy. A good visual outcome was obtained after combining other antiviral molecules to the initial treatment. Methods: Two healthy male patients (aged 40 and 48 years) were referred for progressive visual loss and pain in the right eye (RE). Case 1: Corrected visual acuities were 20/50 in the right eye (RE) and 20/20 in the left eye (LE). Anterior segment examination disclosed a mild inflammation with granulomatous keratic precipitates (GKP) on the inferior part of the corneal endothelium. RE’s fundus examination showed a papillary hyperaemia and a large white necrotic lesion located in the superior para–papillary area, associated with multiple satellite lesions. Case 2: Corrected visual acuities were 20/80 in the RE and 20/20 in the LE. Anterior segment examination disclosed a mild inflammation with GKP's. RE’s fundus examination showed an extensive necrotizing retinitis affecting the superior and nasal area with a para–papillary exsudative retinal detachment and vasculitis. An ARN was suspected. An anterior chamber tap (PCR for HSV1, HSV2, VZV, CMV, EBV and Toxoplasmosis) was performed, before introducing a treatment. Results: The PCR analysis of the aqueous humour was positive for VZV. Patients were treated with intravenous (iv) acyclovir (10 mg/kg/8 hours). After one week, the initial lesion started to heal but multiple satellite lesions appeared in the periphery of the retina in both patients. A viral resistant strain of VZV was suspected. Acyclovir was continued and iv foscarnet (60 mg/kg/8 hours) with intravitreal (ivt) ganciclovir (2000 µg, 1 injection on week 2 and 3) were introduced. IV acyclovir and foscarnet were administered for three weeks. Valacyclovir was introduced for three months. The outcome was favourable with a final vision of 20/20 after a follow up of 30 months (patient 1) and 10 months (patient 2). No systemic nor local complications were observed. Conclusions: These cases demonstrate that a combination of antiviral therapies may be safe and efficacious in the management of necrotizing herpetic retinopathies, affecting immunocomptetent patients, when a viral resistance is suspected.
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