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Acute retinal necrosis — Clinical Guidelines

Overview

Acute retinal necrosis (ARN) is a severe inflammatory condition characterized by peripheral retinal necrosis, often associated with viral infections, typically herpesviruses (herpes simplex virus, varicella-zoster virus). It can lead to significant vision loss if not promptly managed 10.

Diagnosis

Clinical Presentation: Peripheral retinal whitening, retinal vasculitis, and occlusive vasculopathy 10.

Diagnostic Imaging: Fluorescein angiography and optical coherence tomography (OCT) to assess retinal involvement and vascular status 10.

Viral Detection: PCR testing of aqueous humor or vitreous fluid for viral DNA (HSV, VZV) 10.

Fundus Examination: Essential for identifying characteristic lesions and assessing severity 10.

Management

Antiviral Therapy: Intravenous acyclovir (10 mg/kg every 8 hours) or valganciclovir (900 mg daily) for severe cases 10.

Corticosteroids: Adjunctive systemic corticosteroids to reduce inflammation, typically prednisone (initial high dose tapered over weeks) 10.

Monitoring: Regular follow-up with ophthalmologic evaluations to monitor disease progression and treatment response 10.

Surgical Intervention: Vitrectomy may be necessary in cases with vitreous hemorrhage or retinal detachment 10.

Special Populations

Pregnancy: Limited data; management focuses on balancing maternal and fetal safety with aggressive antiviral therapy 10.

Pediatrics: Similar principles apply, but dosing adjustments and close monitoring are crucial due to developmental considerations 10.

Elderly: Increased vigilance for complications and comorbidities; tailored treatment plans considering overall health status 10.

Key Recommendations

Initiate Prompt Antiviral Therapy: Use intravenous acyclovir or valganciclovir for severe cases to prevent further retinal damage (Evidence: Strong) 10.

Incorporate Corticosteroids: Add systemic corticosteroids to reduce inflammation, particularly in cases with significant vitritis (Evidence: Moderate) 10.

Regular Monitoring: Schedule frequent ophthalmologic follow-ups to assess treatment efficacy and detect complications early (Evidence: Moderate) 10.

Consider Surgical Interventions: Evaluate the need for vitrectomy in cases complicated by vitreous hemorrhage or retinal detachment (Evidence: Expert opinion) 10.

References

1 Phélip M, Jondeau C, Bott M, Grillot AE, Chahory S. Accuracy and Reliability of Telediagnosis Approach for Canine and Feline Ophthalmological Emergencies: A Retrospective Study of 100 Cases. Veterinary ophthalmology 2026. link 2 Maciá Fernández MC, Santabrígida Oreja G, Vargas Alvarado LH, Sánchez Bernal S, Valentín Martín AB, Encinas de la Iglesia J. Ophthalmological emergencies. Radiologia 2025. link 3 Khan SA, Gunasekera C. "Comparative analysis of large language models against the NHS 111 online triaging for emergency ophthalmology". Eye (London, England) 2025. link 4 Ray IK, Sobrin L, Moorthy R, Yeh S, Thorne JE, Shantha JG. Common Practice Patterns in the Diagnosis and Management of Acute Retinal Necrosis: A Survey Study of Uveitis Specialists. Ocular immunology and inflammation 2025. link 5 Knebel D, Priglinger S, Scherer N, Klaas J, Siedlecki J, Schworm B. Assessment of ChatGPT in the Prehospital Management of Ophthalmological Emergencies - An Analysis of 10 Fictional Case Vignettes. Klinische Monatsblatter fur Augenheilkunde 2024. link 6 Bergman ZM, Munir SZ, Munir WM. Weather Patterns and the Frequency of Ophthalmology Consultations in the Emergency Setting. Ophthalmic epidemiology 2024. link 7 Dos Santos LM, Arndt C, Hurtaud A, Carolet C, Kritly T, Henry A. [First- and second-line hospital management of ophthalmologic emergencies: Clinical pathway study of 1360 patients]. Journal francais d'ophtalmologie 2023. link 8 Donati S, Appolloni E, Ceriani S, Premi E, Premoli L, Metrangolo C et al.. COVID-19 pandemic and ophthalmological emergencies: a case-control analysis of the impact of lockdowns in a University Hospital in Lombardy region, Italy. Annals of medicine 2023. link 9 Renouvin-Benat A, Sabatier P, Varenne F, Pagot-Mathis V, Fournie P, Malecaze F et al.. [Evaluation of the nurse triage at the ophtalmology emergency department of Pierre-Paul-Riquet Hospital]. Journal francais d'ophtalmologie 2018. link 10 Schoenberger SD, Kim SJ, Thorne JE, Mruthyunjaya P, Yeh S, Bakri SJ et al.. Diagnosis and Treatment of Acute Retinal Necrosis: A Report by the American Academy of Ophthalmology. Ophthalmology 2017. link 11 Magauran B. Conditions requiring emergency ophthalmologic consultation. Emergency medicine clinics of North America 2008. link 12 Rosengren D, Blackwell N, Kelly G, Lenton L, Glastonbury J. The use of telemedicine to treat ophthalmological emergencies in rural Australia. Journal of telemedicine and telecare 1998. link 13 Lönwe B, Heijl A. Computer-assisted instruction in emergency ophthalmological care. Acta ophthalmologica 1993. link

Acute retinal necrosis