Bilateral central retinal artery occlusion associated with herpes simplex virus-associated acute retinal necrosis and meningitis: case report and literature review

Abstract

A 60-year-old woman with a history of recurrent headaches and blurred vision presented with bilateral optic disc edema. Optic neuritis was suspected, and intravenous methylprednisonlone was administered. Her vision declined to hand motions in both eyes, and subsequent evaluation revealed bilateral acute retinal necrosis with bilateral central retinal artery occlusions (CRAO). Aqueous humor polymerase chain reaction analysis was positive for herpes simplex virus (HSV), establishing a diagnosis of HSV-associated bilateral acute retinal necrosis (ARN) and meningitis. CRAO has rarely been reported in association with ARN, and a fulminant course with bilateral CRAO in association with ARN has not been previously reported. This case emphasizes the importance of careful peripheral examination in patients with presumptive optic neuritis, judicious use of systemic corticosteroid in this context, and the retinal vaso-obliterative findings that may be observed in the pathogenesis of ARN.

Figure 1

Fundus photographs and fluorescein angiogram of the right eye. Fundus photograph of the posterior pole of the right eye shows a pale optic nerve, sclerotic retinal vessels and retinal whitening involving the macula (A). Confluent retinal whitening with obliteration of the vessels is observed nasally (B). Fluorescein angiogram of the right eye shows extremely delayed retinal arterial filling at 1:53 (C) with incomplete filling at 5:56 and late leakage of the optic disc (D).

Figure 2

Fundus photographs and fluorescein angiogram of the left eye. Fundus photograph of the posterior pole of the left eye shows similar findings compared to the right eye with optic nerve pallor, retinal vascular obliteration, and pale-appearing macula with retinal whitening (A). Fluorescein angiography shows poor choroidal and central retinal artery filling at 27 seconds (B). Incomplete filling of arterial tree is observed at 1:05 (C). Fluorescein angiogram at 2:19 shows incomplete retinal arterial filling and optic disc leakage (D).