Intravitreal Antiviral Injections as Adjunctive Therapy in the Management of Immunocompetent Patients With Necrotizing Herpetic Retinopathy Kevin K.M. Luu, BS, Ingrid U. Scott, MD, MPH, Nauman A. Chaudhry, MD, Alan Verm, MD, and Janet L. Davis, MD PURPOSE: To report the use of intravitreal antiviral injections as adjunctive therapy in the management of three immunocompetent patients with necrotizing her- petic retinopathy. METHOD: Case series. RESULTS: Three patients with necrotizing herpetic retinop- athy received intravitreal antiviral injections for treatment of progressive retinitis, despite standard intravenous acyclo- vir therapy. The retinitis resolved and visual acuity improved after a minimum of 6 months of follow-up in each case. CONCLUSION: Intravitreal antiviral injections may be a safe and efficacious adjunctive therapy in the manage- ment of patients with necrotizing herpetic retinopathy. (Am J Ophthalmol 2000;129:811– 813. © 2000 by Elsevier Science Inc. All rights reserved.) A CUTE RETINAL NECROSIS HAS BEEN DESCRIBED AS A syndrome that consists of peripheral necrotizing retinitis, retinal arteritis, and vitritis. 1 Subsequently, progressive outer retinal necrosis syndrome has been described as a similar syndrome that occurs in immunocompromised patients. 2 After the herpesviruses were identified as the causative agents of acute retinal necrosis and progressive outer retinal necrosis syndrome, the term necrotizing herpetic retinopathy was used to describe retinal lesions caused by one of the herpesviruses (herpes simplex virus, varicella-zoster virus, or cytomegalovi- rus), and the term currently refers to the spectrum of disease that encompasses both acute retinal necrosis and progressive outer retinal necrosis syndrome. 3 Because necrotizing herpetic retinopathy is caused by herpesviruses, intravenous acyclovir is considered the standard medical treatment. 2,4 Although the use of intravitreal antivirals in immunocompromised patients with progressive outer retinal necrosis syndrome has been described previously, 5,6 we report the use of intravitreal antiviral injections in three immunocompetent patients with necrotizing herpetic retinopathy who failed to achieve an optimal response with standard intravenous acyclovir treat- ment. ● CASE 1: A 46-year-old man was referred with a 1-week history of decreased vision, increasing pain, and photophobia in his right eye. His medical history and review of systems, including human immunodeficiency virus risk factors, were noncontributory. Best-corrected visual acuity was RE: 20/ 80-2 and LE: 20/20-2. Anterior segment examinations of both eyes were unremarkable. Dilated fundus examination of the right eye showed moderate vitritis and confluent periph- eral retinal inflammation inferiorly and temporally, with scattered intraretinal hemorrhages. Examination of the left eye gave normal results. The patient was diagnosed with necrotizing herpetic retinopathy and was admitted after receiving laser demarcation of the area of retinal necrosis in his right eye. He was started on intravenous acyclovir and oral prednisone. Serologic testing for human immunodeficiency virus was negative. On hospital day 5, examination demon- strated progression of the retinitis beyond the area of laser demarcation. Intravitreal injections of ganciclovir (2,000 g/0.05 ml) and foscarnet (1,200 g/0.05 ml) were adminis- tered every other day, for a total of four doses. Serial examinations of the right eye showed resolution of the retinitis; the left eye remained uninvolved. The patient was discharged on acyclovir, 800 mg orally five times per day for 3 months. Six months after treatment, visual acuity had improved to 20/60 with healed retinitis. ● CASE 2: A 54-year-old-woman presented with a 10-day history of acute loss of vision in her right eye. Her medical history and review of systems, including human immunode- ficiency virus risk factors, were unremarkable. Best-corrected visual acuity was RE: hand motions at 3 feet and LE: 20/40. Slit-lamp examination of the right eye disclosed small and medium-sized keratic precipitates with moderate to severe (2–3+) anterior chamber cells. Dilated fundus examination of the right eye demonstrated moderate vitritis and diffuse confluent retinitis with extensive posterior pole involvement. Examination of the left eye was unremarkable. A diagnosis of necrotizing herpetic retinopathy was made, and the patient was started on intravenous acyclovir (500 mg every 8 hours). By day 6, the retinitis showed significant resolution, and the patient was discharged on oral acyclovir (800 mg five times a day for 3 months). Serologic testing for human immunodefi- ciency virus was negative. The patient returned 3 days later complaining of floaters in her left eye. Best-corrected visual acuity was RE: light perception and LE: 20/30. A dilated fundus examination of the left eye showed multiple small yellow retinal lesions temporally, consistent with necrotizing herpetic retinopa- thy. Because these lesions appeared while the patient was taking systemic acyclovir, two intravitreal injections of ganciclovir (2,000 g/0.05 ml) were administered to the left eye 3 days apart. At 1-week follow-up, the lesions had improved significantly. The patient continued to receive oral acyclovir for 3 months. One year after treatment, visual acuity in the right eye was no light perception with Accepted for publication Feb 21, 2000. From the Bascom Palmer Eye Institute, Miami, Florida. This study was supported in part by Research to Prevent Blindness, Inc, New York, New York. Inquiries to Ingrid U. Scott, MD, MPH, Bascom Palmer Eye Institute, 900 NW 17th St, Miami, FL 33136; fax: (305) 326-6417; e-mail: iscott@bpei.med.miami.edu BRIEF REPORTS VOL. 129,NO. 6 811