eMedicine Specialties > Ophthalmology > Retina

Acute Retinal Necrosis: Treatment & Medication

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

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

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

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

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

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

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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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