Diagnosis and Treatment of Acute Retinal Necrosis OTA

A Report by the American Academy of Ophthalmology Ophthalmic Technology Assessment Committee Retina/Vitreous Panel: Scott D. Schoenberger, MD,¹ Stephen J. Kim, MD,² Jennifer E. Thorne, MD, PhD,³ Prithvi Mruthyunjaya, MD,⁴ Steven Yeh, MD,⁵ Sophie J. Bakri, MD,⁶ Justis P. Ehlers, MD⁷

Ophthalmology, March 2017, Vol 124, 382-392 © 2017 by the American Academy of Ophthalmology. Click here for free access to the OTA.

Objective: To evaluate the available evidence in peer-reviewed publications about the diagnosis and treatment of acute retinal necrosis (ARN).

Methods: Literature searches of the PubMed and Cochrane Library databases were last conducted on July 27, 2016. The searches identified 216 unique citations, and 49 articles of possible clinical relevance were reviewed in full text. Of these 49 articles, 27 were deemed sufficiently relevant or of interest, and they were rated according to strength of evidence. An additional 6 articles were identified from the reference lists of the above articles and included. All 33 studies were retrospective.

Results: Polymerase chain reaction (PCR) testing of aqueous or vitreous humor was positive for herpes simplex virus (HSV) or varicella zoster virus (VZV) in 79% to 100% of cases of suspected ARN. Aqueous and vitreous specimens are both sensitive and specific. There is level II and III evidence supporting the use of intravenous and oral antiviral therapy for the treatment of ARN. Data suggest that equivalent plasma drug levels of acyclovir can be achieved after administration of oral valacyclovir or intravenous acyclovir. There is level II and III evidence suggesting that the combination of intravitreal foscarnet and systemic antiviral therapy may have greater therapeutic efficacy than systemic therapy alone. The effectiveness of prophylactic laser or early pars plana vitrectomy (PPV) in preventing retinal detachment (RD) remains unclear.

Conclusions: Polymerase chain reaction testing of ocular fluid is useful in supporting a clinical diagnosis of ARN, but treatment should not be delayed while awaiting PCR results. Initial oral or intravenous antiviral therapy is effective in treating ARN. The adjunctive use of intravitreal foscarnet may be more effective than systemic therapy alone. The role of prophylactic laser retinopexy or early PPV is unknown at this time.

¹Retina Physicians & Surgeons, Inc., Dayton, Ohio
²Department of Ophthalmology, Vanderbilt University School of Medicine, Nashville, Tennessee
³Division of Ocular Immunology, Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
⁴Byers Eye Institute, Stanford University, Palo Alto, California
⁵Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
⁶Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
⁷Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio