Acute Retinal Necrosis Masked by Clinical Features of Orbital Inflammation

Purpose: To describe a case of acute retinal necrosis with clinical features of orbital inflammation. Case summary: A 33-year-old female presented with right eye injection, chemosis, and pain. At the first visit, the uncorrected visual acuity and intraocular pressure of her right eye were 20/20 and 20 mmHg, respectively. Slit-lamp examination showed inflammatory cell 2+ in the anterior chamber of the right eye; an evaluation of the peripheral retina was not conducted. The next day, computed tomography (CT) was performed due to aggravation of the orbital inflammation. High-dose intravenous methyl-prednisolone injection was initiated on the finding of posterior scleritis with orbital inflammation on CT scans; peripheral retinal necrosis and obstructive vasculitis were also noted. Clinically determined to be acute retinal necrosis, the patient began systemic antiviral therapy. A diagnostic anterior chamber paracentesis was positive for herpes simplex virus type 2 by polymerase chain reaction. The patient was treated with intravenous acyclovir and intravitreal injections of foscarnet, as well as barrier laser therapy. After two weeks of treatment, the patient was discharged with oral valacyclovir. During the three months of follow-up, the visual acuity of the right eye was hand motion, due to chronic optic disc swelling with chronic macular edema and macular degeneration. Neither eye showed retinal lesion progression. Conclusions: Rarely, acute retinal necrosis is accompanied by clinical manifestations of orbital inflammation. Therefore, if patients have uveitis with orbital inflammation, it is important to consider the possibility of acute retinal necrosis and to examine the peripheral retina carefully.