OSLI Retina

December 2019

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748 Ophthalmic Surgery, Lasers & Imaging Retina | Healio.com/OSLIRetina Practical Retina Incorporating current trials and technology into clinical practice Update on the Management of Acute Retinal Necrosis by Alexa L. Li, MD; Jessica G. Shantha, MD; and Steven Yeh, MD One in a million. Acute retinal ne- crosis (ARN) — although thankfully rare, with some population-based studies pegging its incidence on the order of one in 1 million — can be a devastating con- dition. The major- ity of patients are relatively young and appear immu- nocompetent and, therefore, unsuspecting of this sight- threatening and occasionally bilateral diagnosis. As such, prompt recogni- tion and treatment of this devastating disorder is paramount to maximize clinical outcomes. Unfortunately, since ARN is such an uncommon condition, retina spe- cialists lack large, randomized, con- trolled trials to offer guidance on optimal management. Controversies persist on best choice of antiviral agent and route of administration as well as if and when to employ corticosteroids. There is debate on whether there is a role for prophylactic laser or even ear- ly prophylactic vitrectomy surgery to reduce the risk of retinal detachment. These controversies are ad- dressed by Alexa L. Li, MD, Jessica G. Shantha, MD, and Steven Yeh, MD, all from Emory University, with an evidence-based approach and discussion of the current literature. They provide a straightforward man- agement algorithm for approaching acute retinal necrosis that astute cli- nicians can employ to combat this devastating condition. INTRODUCTION Acute retinal necrosis (ARN) is an uncom- mon viral uveitic syndrome characterized by a diffuse necrotizing retinitis that can lead to devastating visual consequences if not promptly diagnosed and treated. Due to its rarity, there is a lack of prospective, random- ized, controlled clinical trials in the literature regarding optimal diagnostic and treatment regimens. Retrospective studies have guided current practices, yet recent advances in mo- lecular diagnostics and combination systemic and intravitreal therapies suggest improved outcomes. This review summarizes the most recent developments in the challenging man- agement of patients with ARN. DIAGNOSIS OF ACUTE RETINAL NECROSIS The diagnosis of ARN is classically made through clinical examination based on the following criteria defined by the Executive Committee of the American Uveitis Society in 1994: at least one area of peripheral retinal necrosis with circumferential spread, anterior chamber and vitreous inflammation, occlusive vasculopathy, and rapid disease progression in the absence of therapeutic intervention. 1 Main- taining a clinical suspicion for ARN is critical, and prompt treatment should be administered when the clinical exam is suggestive of ARN. Although laboratory data are not currently listed in the diagnostic criteria for ARN, testing with polymerase chain reaction (PCR) is now widely utilized, as numerous studies have reported PCR testing of viral DNA in aqueous and vitreous samples. 2 Analysis of ocular fluid with PCR testing has heralded a sensitivity and specificity of greater than 90% in the detection of varicella zoster virus (VZV), herpes simplex virus (HSV), and cyto- megalovirus (CMV). 3 Studies have reported PCR positivity for HSV or VZV DNA in 79% to 100% of cases with suspected ARN. 2 Fur- thermore, viral diagnosis can aid in prognostic recommendations for guiding further treatment. Wong et al. reported a greater degree of visual loss in patients with ARN caused by VZV (0.4 logMAR) compared to those caused by HSV (0.04 logMAR; P = .014). 4 Alexa L. Li Jessica G. Shantha Steven Yeh doi: 10.3928/23258160-20191119-01 Howard F. Fine Practical Retina Co-Editor

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