Graefes Arch Clin Exp Ophthalmol DOI 10.1007/s00417-015-3051-x

LETTER TO THE EDITOR

Spectral domain and swept source optical coherence tomography findings in acute retinal necrosis Anna Ohtake-Matsumoto 1 & Hiroshi Keino 1 & Takashi Koto 1 & Annabelle A. Okada 1

Received: 11 February 2015 / Revised: 1 May 2015 / Accepted: 5 May 2015 # Springer-Verlag Berlin Heidelberg 2015

Dear Editor, Acute retinal necrosis (ARN) is a devastating, potentially blinding ocular infection characterized by the clinical feature of progressive retinitis and the histopathological finding of severe retinal necrosis [1–3]. Previously, reduced retinal thickness corresponding to necrotic lesions has been shown using time-domain optical coherence tomography (OCT) [4]. In this report, we analyzed serial OCT images of the macula and peripheral retina in an eye with ARN using the newer generation of OCT devices, including both spectral-domain (SD)OCT and swept-source (SS)-OCT. A 63-year-old woman presented with decreased vision in her left eye of 2 weeks duration. She was otherwise well, although she had a history of systemic lupus erythematosus diagnosed 20 years earlier and herpes simplex virus (HSV)-1 encephalitis diagnosed 4 years earlier. At presentation, the corrected visual acuities were 1.2 in the right eye and 0.02 in the left eye. Examination of the right eye was entirely normal. Slit-lamp examination of the left eye showed keratic precipitates and 2+ anterior chamber cells and flare. Funduscopy of the left eye revealed mild vitreous opacification, extensive retinal inflammation and necrosis in the nasal and inferior periphery extending into the inferior macula, associated with retinal arteritis and optic disc hyperemia (Fig. 1a). Ultrawidefield fluorescein angiography using the Optos 200Tx imaging system (Optos PLC, Dunfermline, UK) demonstrated retinal arterial and venous non-perfusion in 3 quadrants (Fig. 1b). SD-OCT (Heidelberg Engineering, Heidelberg,

* Annabelle A. Okada [email protected] 1

Department of Ophthalmology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, Japan 181-8611

Germany) showed severe macular edema and hyperreflective areas in the inner retinal layer corresponding to yellowish-white lesions seen in the inferior macula (Fig. 1c). ARN was suspected, and subsequent PCR analysis of aqueous humor was positive for HSV-1. Treatment was initiated with an intravitreal injection of ganciclovir (800 μg) in addition to intravenous acyclovir (1500 mg/m2/day) and oral prednisolone (40 mg/day). Two weeks after starting treatment (Fig. 2a), SS-OCT (Topcon Corporation, Tokyo, Japan) showed reduced macular edema; however, the ellipsoid zone was not discernable (Fig. 2b). A hyperreflective line in the inner retina was also observed, and disorganization of the outer retina in the juxtapapillary area appeared to correspond to the yellowish lesions seen by funduscopy (Fig. 2c). At 3 weeks, although the retinitis appeared quiescent, an inferior retinal detachment developed (Fig. 2d). At that time, SS-OCT revealed further improvement in the macular edema. However, retinal thickness in the inferior macula was significantly reduced, with no recovery of the ellipsoid zone (Fig. 2e), and separation of inner retina from outer retina within the inferior retinal detachment was observed (Fig. 2f). Cataract extraction, pars plana vitrectomy, silicone oil tamponade, and scleral buckling were performed. One week after surgery, the corrected visual acuity was 0.1, and funduscopy revealed an attached retina with no evidence of active retinitis. A recent paper has demonstrated diffuse full-thickness retinal hyper-reflectivity and loss of normal retinal architecture corresponding to peripheral necrotic lesions in an ARN patient at presentation using SD-OCT [5]. In our patient, both SD-OCT and SS-OCT modalities revealed marked thinning of the inner and outer retinal layers within areas of retinal necrosis, and showed that the ellipsoid zone was not discernable, either early in the clinical course or during follow-up. This suggests that necrotizing lesions extending into the macula at presentation are associated with irreversible damage, leading to poor central

Graefes Arch Clin Exp Ophthalmol Fig. 1 Fundus photography, ultra-widefield fluorescein angiography, and spectral-domain optical coherence tomography (SD-OCT) images of the left eye at presentation. a Funduscopy revealed mild vitreous opacification, extensive retinal whitening in the nasal (lower panel) and inferior retinal periphery extending into the inferior macula, associated with retinal arteritis and optic disc hyperemia (upper panel). b Ultra wide-field fluorescein angiography using the Optos 200Tx imaging system showed retinal arterial and venous nonperfusion in three quadrants. c SD-OCT revealed severe macular edema and hyper-reflective areas in the inner retinal layer (arrowheads) corresponding to yellowish-white lesions seen in the inferior macula

Fig. 2 Ultra wide-field fundus photography and swept-source optical coherence tomography (SS-OCT) images at 2 weeks (a–c) and 3 weeks (d–f) after starting treatment. a Ultra wide-field fundus photography showed that the retinal lesions had expanded circumferentially. b SSOCT showed reduced macular edema; however, the ellipsoid zone was not discernable. c In addition, SS-OCT showed a hyper-reflective line in the inner retina and disorganization of the outer retina in the juxtapapillary

area (arrowheads) that appeared to correspond to the yellowish lesions seen by funduscopy. d Ultra wide-field fundus photography documented an inferior retinal detachment (arrowheads). e SS-OCT revealed improved macular edema; however, retinal thickness in the inferior macula was markedly reduced (arrowheads), with no recovery of the ellipsoid zone. f SS-OCT showed separation of inner retina from outer retina within the inferior retinal detachment (arrowheads)

Graefes Arch Clin Exp Ophthalmol

Fig. 2 (continued)

vision. In addition, SS-OCT showed schisis-like separation of the inner and outer layers of the retina within an inferior retinal detachment, suggesting that vitreous traction may be playing a large role in the pathogenesis of this complication. We believe that the use of SD-OCT and SS-OCT can contribute to the understanding of the functional consequences of ARN, and may be useful to monitor for early signs of retinal detachment. Further analysis of specific findings, such as absence of ellipsoid zone and hyper-reflectivity in the retina, is required to see if they can guide treatment decisions.

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4. Patient consent The patient has consented to the submission of this case report for publication. 5. Conflict of interest The authors have no conflict of interests in connection with this study.

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