Central retinal artery occlusion as a presenting sign of acute retinal necrosis - A rare finding

Amber A Bhayana; Priyanka Prasad; Shorya V Azad; Akshaya Balaji; Pradeep Venkatesh

doi:10.4103/ijo.IJO_1302_21

PHOTO ESSAY

Year : 2022 | Volume : 2 | Issue : 2 | Page : 579-580

Central retinal artery occlusion as a presenting sign of acute retinal necrosis - A rare finding

Amber A Bhayana, Priyanka Prasad, Shorya V Azad, Akshaya Balaji, Pradeep Venkatesh
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India

Date of Submission	18-May-2021
Date of Acceptance	12-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Shorya V Azad
Dr R P Centre for Ophthalmic Sciences, AIIMS, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1302_21

Abstract

Keywords: Acute retinal necrosis, central retinal artery occlusion, herpes

How to cite this article:
Bhayana AA, Prasad P, Azad SV, Balaji A, Venkatesh P. Central retinal artery occlusion as a presenting sign of acute retinal necrosis - A rare finding. Indian J Ophthalmol Case Rep 2022;2:579-80

How to cite this URL:
Bhayana AA, Prasad P, Azad SV, Balaji A, Venkatesh P. Central retinal artery occlusion as a presenting sign of acute retinal necrosis - A rare finding. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 2];2:579-80. Available from: https://www.ijoreports.in/text.asp?2022/2/2/579/342877

A 35-year-old healthy male with no systemic illness presented with sudden onset diminution of vision in the right eye (RE) for the past 2 weeks. On examination, RE had best corrected visual acuity (BCVA) of counting fingers close to face and a relative afferent pupillary defect. Anterior chamber (AC) had 2+ cells. Retrolental cells were present. Fundus evaluation showed cherry red spot at the posterior pole with retinitis patches in mid-periphery and periphery [Figure 1]a. Fluorescein angiography revealed patchy hyper-fluorescence corresponding to areas of retinitis and pin-point leaks at posterior pole [Figure 1]b and [Figure 1]c. Left eye was within normal limits. A presumptive diagnosis of RE acute retinal necrosis (ARN) with central retinal artery occlusion (CRAO) was made. Patient was started on 1 gm oral valacyclovir thrice a day. Dramatic improvement was noted both symptomatically and clinically. Cherry red spot disappeared and retinitis patches were replaced by pigmentary changes on 10-day follow-up [Figure 2]a. At 3 weeks, AC was quiet and vision improved to 3/60 [Figure 2]b.

Figure 1: (a) Ultrawide field photograph of right eye showing central retinal artery occlusion clinically seen as cherry red spot (black arrow), with inferotemporal and nasal retinal necrosis (red arrows); (b and c) fluorescein angiography showing pin point leaks (green arrow) at posterior pole and necrotic patches as hyperfluorescence (red arrows) in inferotemporal and nasal retina

Click here to view

Figure 2: Right eye fundus picture at (a) 10 days and (b) 3 weeks showing pigmentary changes (blue arrows) at areas of retinal necrosis

Click here to view

Discussion

Fahle et al. published a series of three serology proven cases of ARN. All these cases had CRAO along with vitritis and retinitis except one who had concurrent central retinal vein occlusion (CRVO).^[1] Similarly, Kang and Kim described unilateral combined CRAO with CRVO, subsequently developing necrotic retinal patches in the fellow eye, indicating ARN.^[2] Shah et al.^[3] reported a patient with acute anterior uveitis who later developed CRAO with cilioretinal sparing (herpes DNA on PCR). Weissman et al. also reported a case of bilateral ARN who presented with disc edema and CRAO in due course.^[4] The aforementioned patients were all in fifth decade or above, with history of some form of systemic illness (coronary artery disease, stroke, hodgkin's lymphoma etc). Our patient, however, was a young male with no systemic illness. Presentation with anterior chamber inflammation, vitritis, CRAO, and peripheral patches of retinitis suggested ARN. The diagnosis was purely clinical, reinforced by the rapid resolution after starting antiviral therapy. Gene amplifying tests or other diagnostic lab investigations were not possible due to shutdown of services because of ongoing COVID-19 pandemic.

CRAO can be a presenting sign in cases of ARN that can be seen even in immunocompetent and young individuals.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Yeh S, Fahle G, Flaxel CJ, Francis PJ. Central retinal vascular occlusion associated with acute retinal necrosis. Arch Ophthalmol 2012;130:514-7.
2.	Kang SW, Kim SK. Optic neuropathy and central retinal vascular obstruction as initial manifestations of acute retinal necrosis. Jpn J Ophthalmol 2021;45:425-42.
3.	Shah SP, Hadid OH, Graham EM, Stanford MR. Acute retinal necrosis presenting as central retinal artery occlusion with cilioretinal sparing. Eur J Ophthalmol 2005;15:287-8.
4.	Weissman HM, Biousse V, Schechter MC, Del Rio C, Yeh S. Bilateral central retinal artery occlusion associated with herpes simplex virus-associated acute retinal necrosis and meningitis: Case report and literature review. Ophthalmic Surg Lasers Imaging Retina 2015;46:279-83.