Case Report Full thickness macular hole without necrosis in a case of viral retinitis Sangeeta Roy 1 , Brijesh Takkar 2,3 , Priyanka Khandelwal 4 and Rohan Chawla 5 Keywords Viral infection, Disease, Ocular, Physiology Case report A 32-year-old woman presented with sudden painful visual loss associated with photophobia in both eyes. She denied any history of prior systemic or ocular dis- ease. Best corrected visual acuity (BCVA) was counting fingers at 1 m in the right eye (RE) and 2/60 in left eye (LE). Slit lamp examination revealed severe anterior chamber reaction (white keratic precipitates, 4þ cells and 2þ flare), along with severe vitritis. There was grade 3 media haze in both eyes (Endophthalmitis Vitrectomy Study Group), though some yellowish patches suggestive of retinitis could be seen (Figure 1a, b). Macular details were hazy. Leading questions revealed a history of orogenital ulcers over the previous fortnight. Her husband also had similar lesions. With an empirical diagnosis of infective uveitis and retinitis, medical therapy with topical steroids and cycloplegia, together with oral valacyclovir (1 gm b.i.d.) and doxycycline (100 mg b.i.d.) were initiated with a plan to add oral steroids subsequently. Both husband and wife were found to be serologically posi- tive for herpes simplex virus 2 (IgM-ELISA), but nega- tive for HIV and syphilis. Our patient was therefore diagnosed as having acute retinal necrosis (ARN) and uveitis secondary to herpes simplex virus 2. The doxy- cycline was withdrawn, topical and anti-viral therapy continued, as well as oral prednisolone (1 mg/kg) which was added after three days. The orogenital ulcers of both partners were managed with oral valacyclovir. At one-week follow-up, ocular inflammation had reduced and a macular lesion was vaguely visible in the RE. At three weeks, BCVA was 6/36 (RE) and 6/18 (LE). Clinical examination showed arterial thinning and macular ischaemia in both eyes (RE >> LE) with a full thickness macular hole (FTMH) in the RE (Figure 1c and d). Optical coherence tomography (OCT) scan revealed this to be a large macular hole without separation of the posterior vitreous cortex, while macular atrophy was seen in the LE. The hole measured a maximum of 240 mm in height and 1247 mm at its base. There was no evidence of traction or cystoid oedema, though the base of the hole had pig- ment clumps (Figure 2). Dosage of valacyclovir was tapered and stopped after six weeks; the same with pred- nisolone. The patient’s genital lesions resolved with ther- apy. Thereafter, the patient was unfortunately lost to follow-up, precluding evaluation of her macular ischae- mia with fundus angiography. Informed consent was obtained from the patient. Discussion Viral retinitis is usually caused by herpes simplex and sometimes by herpes zoster. It can present acutely or non-acutely in immunocompetent patients, while in the latter necrosis may be absent. Progressive outer retinal necrosis is seen in immunosuppressed patients. 1 Consultant ophthalmologist, Susrut Eye Foundation and Research Centre, Salt Lake City, Kolkota, India 2 Retina and Uvea Services, Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India 3 Assistant Professor, Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal, India 4 Fellow of vitreo retina services at the centre, Susrut Eye Foundation and Research Centre, Salt Lake City, Kolkota, India 5 Assistant Professor, Retina and Uvea Services, Dr RP Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India Corresponding author: BrijeshTakkar, Assistant Professor, Department of Ophthalmology, All India Institute of Medical Sciences, Bhopal 460020, India. Email: britak.aiims@gmail.com Tropical Doctor 0(0) 1–3 ! The Author(s) 2018 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475518766126 journals.sagepub.com/home/tdo