NECROTIZING HERPETIC RETINOPATHY AFTER INTRAVITREAL TRIAMCINOLONE ACETONIDE INJECTION Robert A. Sisk, MD,* Robert K. Hutchins, MD*†
Purpose: To report a new complication of intravitreal triamcinolone acetonide (TA) injection. Methods: In this observational case report, an 87-year-old woman received an intravitreal injection of TA as an adjunct to photodynamic therapy for wet age-related macular degeneration in the left eye. Four months later, she developed ipsilateral necrotizing herpetic retinopathy (NHR). Results: Retinal whitening of the macula was noted in the absence of vitritis that progressed over 5 days to diffuse retinitis with moderate vitritis and anterior chamber cell. Visual acuity decreased from 20/30 to 20/400. TA was still present inferiorly in the vitreous cavity. Polymerase chain reaction testing of samples obtained by vitrectomy with vitreous aspiration and retinal biopsy demonstrated varicella-zoster virus DNA. Two weeks later, repeated vitrectomy, silicone oil injection, and implantation of a ganciclovir sustainedrelease device were performed. Final visual acuity was 5/200. Conclusions: NHR can develop as a complication of intravitreal TA injection in an eye with a history of herpes zoster ophthalmicus. RETINAL CASES & BRIEF REPORTS 1:211–212, 2007
From the *Department of Ophthalmology, University of Cincinnati College of Medicine, and the †Cincinnati Eye Institute, Cincinnati, Ohio.
have been described in patients receiving treatment with systemic corticosteroids.1,2 We are unaware of any previous confirmed report of NHR after intravitreal triamcinolone acetonide (TA) injection.
N
ecrotizing herpetic retinopathy (NHR) is a rare, unrelenting manifestation of herpesvirus reactivation that leads to severe visual loss despite aggressive treatment. It was originally described in young, otherwise healthy patients as the acute retinal necrosis syndrome. Subsequently, with the rise in human immunodeficiency virus infection in the 1980s and 1990s, a new syndrome of progressive outer retinal necrosis was found in association with acquired immune deficiency syndrome. Multiple cases of NHR
Case Report An 87-year-old woman who had a history of a diskiform scar due to age-related macular degeneration in the right eye presented with extrafoveal occult choroidal neovascularization in the left eye. Best-corrected visual acuity was 20/100 in the right eye and 20/30 in the left eye. After krypton red laser photocoagulation was performed, fluorescein angiography disclosed a subfoveal recurrence of choroidal neovascularization in the left eye. She underwent photodynamic therapy with adjunctive intravitreal TA injection. Ten years earlier, she had been treated for herpes zoster ophthalmicus with conjunctivitis in the left eye. Postoperative visits 1 week, 1 month, and 3 months after photodynamic therapy and intravitreal TA injection revealed stable visual acuity in the left eye and no significant change in the fundus appearance. Four months after the injection, the patient reported a 2-day history of decreased vision in the left eye. Best-corrected visual acuity had decreased to 20/100 in the left eye. Examination revealed deep retinal whitening near the optic disk, along the
Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. (New York, NY), to the Department of Ophthalmology, University of Cincinnati College of Medicine (J. Augsburger, MD, Chairman). The authors have no proprietary interest in any aspect of this report. Reprint requests: Robert A. Sisk, MD, 3233 Eden Avenue, Cincinnati, OH 45267; e-mail: [email protected]
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device, and vitreous aspiration with collection of a small piece of retina for culture and polymerase chain reaction testing. Foscarnet (2,400 g/0.1 mL) was injected into the vitreous cavity at the end of the procedures. Over the next 3 weeks, diffuse retinitis accompanied by a moderate inflammatory response developed, resulting in rhegmatogenous retinal detachment. Vitreous cultures failed to yield bacteria or fungi, and polymerase chain reaction testing for herpes simplex virus, Toxoplasma gondii, and cytomegalovirus were negative. Polymerase chain reaction testing was positive for varicella-zoster virus. The retinal detachment was repaired by means of posterior vitrectomy and silicone oil tamponade. The retina remained attached with widespread outer retinal atrophy and retinal pigment epithelial mottling. Final visual acuity was 5/200 in the left eye.
Discussion Patients with a medical history of herpetic encephalitis, meningitis, or shingles appear to be at increased risk for developing NHR.2,3 This risk is significantly increased in the setting of immune suppression, and the severity of the phenotype of NHR is worse commensurate with the degree of immune suppression.4 This case represents a rare but visually devastating potential complication of intravitreal TA injection in an eye that previously had herpesvirus reactivation in the form of herpes zoster ophthalmicus. Despite the association demonstrated here of intravitreal TA injection with NHR, a history of herpes zoster ophthalmicus does not contraindicate intravitreal TA injection based solely on this case report. Key words: acute retinal necrosis, intravitreal injection, intravitreal triamcinolone acetonide, necrotizing herpetic retinopathy. References Fig. 1. Patient with necrotizing herpetic retinopathy. A, Development of deep retinal whitening heralding retinal necrosis after intravitreal triamcinolone acetonide injection. B, Retinal whitening along the midzonal fundus in the same eye.
superior vascular arcade, and in the midzonal fundus (Fig. 1). There were no other signs of inflammation. TA was still present inferiorly in the vitreous cavity. The optic disk showed mild pallor of the rim, and confrontational visual field testing revealed a deficit in the inferior hemifield. The patient was immediately treated with oral valacyclovir (1 g three times per day) and promptly underwent posterior vitrectomy to remove the TA, implantation of a ganciclovir sustained-release
1. 2.
3.
4.
Browning DJ. Acute retinal necrosis following epidural steroid injections. Am J Ophthalmol 2003;136:192–194. Verma L, Venkatesh P, Satpal G, et al. Bilateral necrotizing herpetic retinopathy three years after herpes simplex encephalitis following pulse corticosteroid treatment. Retina 1999;19: 464–467. Ganatra JB, Chandler D, Santos C, et al. Viral causes of the acute retinal necrosis syndrome. Am J Ophthalmol 2000;129: 166–172. Guex-Crosier Y, Rochat C, Herbort CP. Necrotizing herpetic retinopathies. A spectrum of herpes virus-induced diseases determined by the immune state of the host. Ocul Immunol Inflamm 1997;5:259–265.
Purpose: To report a new complication of intravitreal triamcinolone acetonide (TA) injection. Methods: In this observational case report, an 87-year-old woman received an intravitreal injection of TA as an adjunct to photodynamic therapy for wet age-related macular degeneration in the left eye. Four months later, she developed ipsilateral necrotizing herpetic retinopathy (NHR). Results: Retinal whitening of the macula was noted in the absence of vitritis that progressed over 5 days to diffuse retinitis with moderate vitritis and anterior chamber cell. Visual acuity decreased from 20/30 to 20/400. TA was still present inferiorly in the vitreous cavity. Polymerase chain reaction testing of samples obtained by vitrectomy with vitreous aspiration and retinal biopsy demonstrated varicella-zoster virus DNA. Two weeks later, repeated vitrectomy, silicone oil injection, and implantation of a ganciclovir sustainedrelease device were performed. Final visual acuity was 5/200. Conclusions: NHR can develop as a complication of intravitreal TA injection in an eye with a history of herpes zoster ophthalmicus. RETINAL CASES & BRIEF REPORTS 1:211–212, 2007
From the *Department of Ophthalmology, University of Cincinnati College of Medicine, and the †Cincinnati Eye Institute, Cincinnati, Ohio.
have been described in patients receiving treatment with systemic corticosteroids.1,2 We are unaware of any previous confirmed report of NHR after intravitreal triamcinolone acetonide (TA) injection.
N
ecrotizing herpetic retinopathy (NHR) is a rare, unrelenting manifestation of herpesvirus reactivation that leads to severe visual loss despite aggressive treatment. It was originally described in young, otherwise healthy patients as the acute retinal necrosis syndrome. Subsequently, with the rise in human immunodeficiency virus infection in the 1980s and 1990s, a new syndrome of progressive outer retinal necrosis was found in association with acquired immune deficiency syndrome. Multiple cases of NHR
Case Report An 87-year-old woman who had a history of a diskiform scar due to age-related macular degeneration in the right eye presented with extrafoveal occult choroidal neovascularization in the left eye. Best-corrected visual acuity was 20/100 in the right eye and 20/30 in the left eye. After krypton red laser photocoagulation was performed, fluorescein angiography disclosed a subfoveal recurrence of choroidal neovascularization in the left eye. She underwent photodynamic therapy with adjunctive intravitreal TA injection. Ten years earlier, she had been treated for herpes zoster ophthalmicus with conjunctivitis in the left eye. Postoperative visits 1 week, 1 month, and 3 months after photodynamic therapy and intravitreal TA injection revealed stable visual acuity in the left eye and no significant change in the fundus appearance. Four months after the injection, the patient reported a 2-day history of decreased vision in the left eye. Best-corrected visual acuity had decreased to 20/100 in the left eye. Examination revealed deep retinal whitening near the optic disk, along the
Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc. (New York, NY), to the Department of Ophthalmology, University of Cincinnati College of Medicine (J. Augsburger, MD, Chairman). The authors have no proprietary interest in any aspect of this report. Reprint requests: Robert A. Sisk, MD, 3233 Eden Avenue, Cincinnati, OH 45267; e-mail: [email protected]
211
212
RETINAL CASES & BRIEF REPORTSℜ
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2007
●
VOLUME 1
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NUMBER 4
device, and vitreous aspiration with collection of a small piece of retina for culture and polymerase chain reaction testing. Foscarnet (2,400 g/0.1 mL) was injected into the vitreous cavity at the end of the procedures. Over the next 3 weeks, diffuse retinitis accompanied by a moderate inflammatory response developed, resulting in rhegmatogenous retinal detachment. Vitreous cultures failed to yield bacteria or fungi, and polymerase chain reaction testing for herpes simplex virus, Toxoplasma gondii, and cytomegalovirus were negative. Polymerase chain reaction testing was positive for varicella-zoster virus. The retinal detachment was repaired by means of posterior vitrectomy and silicone oil tamponade. The retina remained attached with widespread outer retinal atrophy and retinal pigment epithelial mottling. Final visual acuity was 5/200 in the left eye.
Discussion Patients with a medical history of herpetic encephalitis, meningitis, or shingles appear to be at increased risk for developing NHR.2,3 This risk is significantly increased in the setting of immune suppression, and the severity of the phenotype of NHR is worse commensurate with the degree of immune suppression.4 This case represents a rare but visually devastating potential complication of intravitreal TA injection in an eye that previously had herpesvirus reactivation in the form of herpes zoster ophthalmicus. Despite the association demonstrated here of intravitreal TA injection with NHR, a history of herpes zoster ophthalmicus does not contraindicate intravitreal TA injection based solely on this case report. Key words: acute retinal necrosis, intravitreal injection, intravitreal triamcinolone acetonide, necrotizing herpetic retinopathy. References Fig. 1. Patient with necrotizing herpetic retinopathy. A, Development of deep retinal whitening heralding retinal necrosis after intravitreal triamcinolone acetonide injection. B, Retinal whitening along the midzonal fundus in the same eye.
superior vascular arcade, and in the midzonal fundus (Fig. 1). There were no other signs of inflammation. TA was still present inferiorly in the vitreous cavity. The optic disk showed mild pallor of the rim, and confrontational visual field testing revealed a deficit in the inferior hemifield. The patient was immediately treated with oral valacyclovir (1 g three times per day) and promptly underwent posterior vitrectomy to remove the TA, implantation of a ganciclovir sustained-release
1. 2.
3.
4.
Browning DJ. Acute retinal necrosis following epidural steroid injections. Am J Ophthalmol 2003;136:192–194. Verma L, Venkatesh P, Satpal G, et al. Bilateral necrotizing herpetic retinopathy three years after herpes simplex encephalitis following pulse corticosteroid treatment. Retina 1999;19: 464–467. Ganatra JB, Chandler D, Santos C, et al. Viral causes of the acute retinal necrosis syndrome. Am J Ophthalmol 2000;129: 166–172. Guex-Crosier Y, Rochat C, Herbort CP. Necrotizing herpetic retinopathies. A spectrum of herpes virus-induced diseases determined by the immune state of the host. Ocul Immunol Inflamm 1997;5:259–265.
