eMedicine Specialties > Ophthalmology > Retina

Acute Retinal Necrosis: Differential Diagnoses & Workup

Author: Andrew A Dahl, MD, Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine
Coauthor(s): David T Wong, MD, FRCS(C), Associate Professor of Ophthalmology, Director of Fellowship Programs, Department of Ophthalmology, St Michael's Hospital, Faculty of Medicine, University of Toronto, Canada; Saad Waheeb, MB, BCh, FRCS(C), Consulting Staff, Department of Ophthalmology, King Abdulaziz University Hospital
Contributor Information and Disclosures

Updated: Jan 21, 2009

Differential Diagnoses

Behcet Disease
Sarcoidosis
Endophthalmitis, Fungal
Toxoplasmosis
HIV
Ocular Manifestations of Syphilis
Retinitis, CMV

Other Problems to Be Considered

Reticulum cell sarcoma

Workup

Laboratory Studies

  • Acute retinal necrosis (ARN) is a clinical diagnosis,4,5 and laboratory tests may not be conclusive.
  • Viral titers may be helpful.
    • Herpes simplex virus 1
    • Herpes simplex virus 2
    • Varicella-zoster virus
  • For baseline, obtain the following:
    • Complete blood cell count
    • Renal function tests
    • Liver function tests

Imaging Studies

  • Fluorescein angiography
    • Not diagnostic
    • Early decrease in choroidal perfusion
    • May show delayed arterial filling
    • Hypofluorescence in areas of active lesions
  • Ocular ultrasound
    • Can rule out retinal detachment in the presence of media opacity
    • May show enlarged optic nerve sheath6
  • CT scan may show optic nerve sheath enlargement.
  • MRI may demonstrate concurrent lesions of the optic tract and the lateral geniculate body, suggesting axonal spread.

Procedures

  • Lumbar puncture may show cerebrospinal fluid pleocytosis.

Staging

  • Stage 1 - Necrotizing retinitis
    • Stage 1a - Discrete areas of peripheral retinitis
    • Stage 1b - Confluent areas of peripheral retinitis, papillitis, macular edema
  • Stage 2 - Vitreous opacification or organization
  • Stage 3 - Regression of retinal necrosis, secondary pigmentation of the lesion with condensation of the vitreous base
  • Stage 4 - Retinal detachment
  • Stage 4a - Acute retinal tears or detachment with traction or proliferative vitreoretinopathy
  • Stage 4b - Chronic retinal detachment

More on Acute Retinal Necrosis

Overview: Acute Retinal Necrosis
Differential Diagnoses & Workup: Acute Retinal Necrosis
Treatment & Medication: Acute Retinal Necrosis
Follow-up: Acute Retinal Necrosis
Multimedia: Acute Retinal Necrosis
References
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References

  1. Muthiah MN, Michaelides M, Child CS, Mitchell SM. Acute retinal necrosis: a national population-based study to assess the incidence, methods of diagnosis, treatment strategies and outcomes in the UK. Br J Ophthalmol. Nov 2007;91(11):1452-5. [Medline].

  2. Walters G, James TE. Viral causes of the acute retinal necrosis syndrome. Curr Opin Ophthalmol. Jun 2001;12(3):191-5. [Medline].

  3. Moesen I, Khemka S, Ayliffe W. Acute retinal necrosis secondary to herpes simplex virus type 2 with preexisting chorioretinal scarring. J Pediatr Ophthalmol Strabismus. Jan-Feb 2008;45(1):59-61. [Medline].

  4. Duker JS, Blumenkranz MS. Diagnosis and management of the acute retinal necrosis (ARN) syndrome. Surv Ophthalmol. Mar-Apr 1991;35(5):327-43. [Medline].

  5. Holland GN. Standard diagnostic criteria for the acute retinal necrosis syndrome. Executive Committee of the American Uveitis Society. Am J Ophthalmol. May 15 1994;117(5):663-7. [Medline].

  6. Sergott RC, Belmont JB, Savino PJ, Fischer DH, Bosley TM, Schatz NJ. Optic nerve involvement in the acute retinal necrosis syndrome. Arch Ophthalmol. Aug 1985;103(8):1160-2. [Medline].

  7. Aizman A. Treatment of acute retinal necrosis syndrome. Drugs Today (Barc). Aug 2006;42(8):545-51. [Medline].

  8. Aizman A, Johnson MW, Elner SG. Treatment of acute retinal necrosis syndrome with oral antiviral medications. Ophthalmology. Feb 2007;114(2):307-12. [Medline].

  9. Blumenkranz MS, Culbertson WW, Clarkson JG, Dix R. Treatment of the acute retinal necrosis syndrome with intravenous acyclovir. Ophthalmology. Mar 1986;93(3):296-300. [Medline].

  10. Emerson GG, Smith JR, Wilson DJ, Rosenbaum JT, Flaxel CJ. Primary treatment of acute retinal necrosis with oral antiviral therapy. Ophthalmology. Dec 2006;113(12):2259-61. [Medline].

  11. Khurana RN, Charonis A, Samuel MA, Gupta A, Tawansy KA. Intravenous foscarnet in the management of acyclovir-resistant herpes simplex virus type 2 in acute retinal necrosis in children. Med Sci Monit. Dec 2005;11(12):CS75-8. [Medline].

  12. Lau CH, Missotten T, Salzmann J, Lightman SL. Acute retinal necrosis features, management, and outcomes. Ophthalmology. Apr 2007;114(4):756-62. [Medline].

  13. Carney MD, Peyman GA, Goldberg MF, et al. Acute retinal necrosis. Retina. Spring-Summer 1986;6(2):85-94. [Medline].

  14. Fisher JP, Lewis ML, Blumenkranz M, et al. The acute retinal necrosis syndrome. Part 1: Clinical manifestations. Ophthalmology. Dec 1982;89(12):1309-16. [Medline].

  15. Gariano RF, Berreen JP, Cooney EL. Progressive outer retinal necrosis and acute retinal necrosis in fellow eyes of a patient with acquired immunodeficiency syndrome. Am J Ophthalmol. Sep 2001;132(3):421-3. [Medline].

  16. Nussenblatt RB, Palestine AG. Acute retinal necrosis. In: Uveitis: Fundamentals and Clinical Practice. 1989:407-14.

  17. Park SS, Holz HA, Ravage ZB, Merrill PT, Nguyen QD. Diagnostic and therapeutic challenges. Acute retinal necrosis syndrome. Retina. Apr 2008;28(4):660-4. [Medline].

  18. Rodriguez A, Calonge M, Pedroza-Seres M, et al. Referral patterns of uveitis in a tertiary eye care center. Arch Ophthalmol. May 1996;114(5):593-9. [Medline].

  19. Severin M, Neubauer H. Bilateral acute vascular retinal necrosis. Ophthalmologica. 1981;182(4):199-203. [Medline].

  20. Tan JCH, Byles D, Stanford MR, Frith PA, Graham EM. Acute retinal necrosis in children caused by herpes simplex virus. Retina. 2001;21(4):344-7. [Medline].

  21. Urayama A, Yamada N, Sasaki T. Unilateral acute uveitis with retinal periarteritis and detachment. Jpn J Clin Ophthalmol. 1971;25:607.

  22. Young NJ, Bird AC. Bilateral acute retinal necrosis. Br J Ophthalmol. Sep 1978;62(9):581-90. [Medline].

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Further Reading

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Keywords

ARN, bilateral acute retinal necrosis, BARN, bilateral ARN, Kirisawa's uveitis, Kirisawa uveitis, blindness, retinal detachment, uveitis, red eye, eye pain, periorbital pain, decreased vision, vision problems, herpes simplex virus 1, HSV-1, herpes simplex virus 2, HSV-2, varicella-herpes zoster virus, VZV

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Contributor Information and Disclosures

Author

Andrew A Dahl, MD, Director of Ophthalmology Teaching, Mid-Hudson Family Practice Institute, The Institute for Family Health; Assistant Professor of Surgery (Ophthalmology), New York College of Medicine
Andrew A Dahl, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, American Society of Cataract and Refractive Surgery, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

David T Wong, MD, FRCS(C), Associate Professor of Ophthalmology, Director of Fellowship Programs, Department of Ophthalmology, St Michael's Hospital, Faculty of Medicine, University of Toronto, Canada
David T Wong, MD, FRCS(C) is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, College of Physicians and Surgeons of Ontario, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Alcon Consulting fee Consulting; Novartis Consulting fee Consulting; Alcon Grant/research funds Other; Labtician Consulting fee Consulting

Saad Waheeb, MB, BCh, FRCS(C), Consulting Staff, Department of Ophthalmology, King Abdulaziz University Hospital
Saad Waheeb, MB, BCh, FRCS(C) is a member of the following medical societies: American Academy of Ophthalmology, Canadian Ophthalmological Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Brian A Phillpotts, MD, Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine
Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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