eMedicine Specialties > Ophthalmology > Retina
Acute Retinal Necrosis: Treatment & Medication
Updated: Jan 21, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Acute retinal necrosis (ARN) treatment consists of the following:7
- Antiviral therapy, including intravenous acyclovir, oral valacyclovir, oral famciclovir, or intravitreal foscarnet, valacyclovir, or famciclovir.8,9,10,11
- Anti-inflammatory therapy
- Antithrombotic therapy
- Retinal detachment prophylaxis
Surgical Care
Surgery is required when retinal detachment occurs.
- Vitrectomy
- Endolaser
- Possible scleral buckle
- Intraocular tamponade - Silicone oil is the usual choice due to the multiple necrotic/atrophic retinal holes (Swiss cheese appearance).
- C3 F8 (octafluoropropane/perfluoropropane) or other fluoridated gases for temporary absorbable intraocular tamponade
Consultations
Infectious disease specialist or internist
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antivirals
Antivirals reduce progression of virus in affected eye as well as protection of the other eye.
Acyclovir (Zovirax)
Has affinity for viral thymidine kinase and once phosphorylated causes DNA chain termination when acted on by DNA polymerase. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.
Adult
1500 mg/m2/d IV divided tid for 7-10 d, followed by 800 mg PO 5 times/d for 14 wk to reduce risk of bilateral involvement
Pediatric
Not established; discuss with pediatrician or infectious disease specialist
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity of acyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or when using nephrotoxic drugs
Ganciclovir (Cytovene, Vitrasert)
Synthetic guanine derivative active against cytomegalovirus (CMV). An acyclic nucleoside analog of 2'-deoxyguanosine that inhibits replication of herpes viruses both in vitro and in vivo.
Levels of ganciclovir-triphosphate are as much as 100-fold greater in CMV-infected cells than in uninfected cells, possibly due to preferential phosphorylation of ganciclovir in virus-infected cells.
For patients who experience progression of CMV retinitis while receiving a maintenance treatment with either dosage form of ganciclovir, the re-induction regimen should be administered.
Adult
5 mg/kg IV q12h for 2 wk
4.5 mg intravitreal implant for 5 to 8 mo; following depletion of ganciclovir, as evidenced by progression of retinitis, implant may be removed and replaced
Pediatric
Not established; discuss with pediatrician or infectious disease specialist
Concomitant administration with cytotoxic drugs such as dapsone, vinblastine, Adriamycin, pentamidine, flucytosine, vincristine, amphotericin B, trimethoprim/sulfamethoxazole combinations, or other nucleoside analogs may result in additive toxicity in bone marrow, spermatogonia, and germinal layers of skin and GI mucosa (coadminister only if potential benefits outweigh risks); coadministration with imipenem-cilastatin may cause generalized seizures (use only if potential benefits outweigh risks); serum creatinine may increase following concurrent use of ganciclovir with either cyclosporine or amphotericin B; in presence of probenecid, ganciclovir renal clearance is reduced; bioavailability may increase when didanosine is administered either 2 h prior to or simultaneously with ganciclovir; bioavailability of ganciclovir may decrease in presence of zidovudine, while bioavailability of zidovudine is increased in presence of ganciclovir
Documented hypersensitivity; do not use if absolute neutrophil count <500 million cells/L or the platelet count is <25 x 109 cells/L
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Clinical toxicity of ganciclovir includes granulocytopenia, anemia, and thrombocytopenia; since oral ganciclovir is associated with higher rate of CMV retinitis progression, compared to IV formulation, use only when benefits outweigh risks (advanced HIV disease); half-life and plasma/serum concentrations of ganciclovir may be increased as a result of reduced renal clearance; dosages >6 mg/kg IV may result in increased toxicity; rapid infusions may result in increased toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (11); phlebitis or pain may occur at site of IV infusion despite further dilution in IV fluids; administration of ganciclovir should be accompanied by adequate hydration; photosensitization (photoallergy or phototoxicity) may occur
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
1 g tid until resolution; taper over 3-6 mo
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity of valacyclovir
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure (decrease dose) and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Famciclovir (Famvir)
After ingestion, drug is rapidly biotransformed into active compound penciclovir and phosphorylated by viral thymidine kinase. By competition with deoxyguanosine triphosphate, penciclovir triphosphate inhibits viral polymerase subsequently inhibiting viral DNA synthesis/replication.
Adjust dose in patients with renal insufficiency or hepatic disease.
Used against herpes simplex and varicella-zoster viruses.
Adult
500 mg PO tid until resolution; taper over 3-6 mo
Pediatric
Not established
Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or coadministration of nephrotoxic drugs
Foscarnet (Foscavir)
Analog of pyrophosphate. Inhibits DNA polymerase of CMV and reverse transcriptase of HIV. Virostatic; renal excretion. As effective as ganciclovir. Median time to relapse on Rx is 53 d. Foscarnet/ganciclovir CMV retinitis trial: 234 newly diagnosed patients randomized. Same efficacy for controlling retinitis and preserving vision. Survival with foscarnet 12.6 mo versus 8.5 for ganciclovir group; mortality risk 1.79x. Controlling for antiretroviral use, still better survival with foscarnet. Foscarnet has anti-HIV activity but has more dose-limiting toxicity.
Adult
Intravitreal injection: 2400 mcg/0.1 mL qwk
Pediatric
Administer as in adults
Avoid administration with potentially nephrotoxic drugs (eg, aminoglycosides, amphotericin B, IV pentamidine) may increase nephrotoxicity (do not administer unless potential benefits outweigh risks); coadministration with IV pentamidine may cause hypocalcemia
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause decline in renal function; for correct dosing, obtain 24-h serum creatinine at baseline and continue to monitor (discontinue if serum creatinine <0.4 mL/min/kg); hydration may reduce nephrotoxicity
Carefully monitor electrolytes (eg, calcium, magnesium); assess for electrolyte and mineral level abnormalities if mild perioral numbness, paresthesias symptoms, or seizures; granulocytopenia and anemia may occur (regularly monitor CBC)
Infuse foscarnet solutions into veins with adequate blood flow to avoid local irritation; to avoid toxicity do not administer by rapid or bolus IV injection
Anti-inflammatory agents
These agents systemically interfere with events leading to inflammation.
Prednisone (Deltasone, Orasone, Meticorten)
May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
0.5-1 mg/kg/d PO qd or divided bid for 8 wk
Ophthalmic: 1 gtt q1h to qid
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections and fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Antiplatelets
Antiplatelets inhibit the cyclooxygenase system, decreasing the level of thromboxane A2, which is a potent platelet activator.
Aspirin (Bayer Aspirin, Ascriptin, Anacin)
Treats mild to moderate pain and headache. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Adult
325 mg PO qd
Pediatric
Not established
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose lowering effect of sulfonylurea drugs
Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, nasal polyps, asthma; due to association of aspirin with Reye syndrome, do not use in children (<16 y) with flu
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants
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
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Further Reading
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
Treatment & Medication: Acute Retinal Necrosis