Ophthalmic Surgery, Lasers and Imaging Retina

Case Report 

Implantation of Foldable Capsular Vitreous Body for the Treatment of Acute Retinal Necrosis Syndrome: A Case Report

Liang Zhang, MMED; Jingwen Liu, MMED; Shenwen Liu, MMED; Bo Qin, MD, PHD

Abstract

The authors present the case of a 35-year-old male who was diagnosed with acute retinal necrosis syndrome that evolved into retinal detachment (RD), even after immediate treatment with systemic antiviral medications, as well as intravitreal injection and laser photocoagulation. Pars plana vitrectomy plus silicone oil tamponade was performed, but silicone oil emulsified 22 months later. Due to the widespread necrosis lesions and defects of the peripheral retina, RD was highly likely to reoccur after silicone oil removal; thus, foldable capsular vitreous body was implanted to support the retina. No recurrent RD was observed afterward.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:653–657.]

Abstract

The authors present the case of a 35-year-old male who was diagnosed with acute retinal necrosis syndrome that evolved into retinal detachment (RD), even after immediate treatment with systemic antiviral medications, as well as intravitreal injection and laser photocoagulation. Pars plana vitrectomy plus silicone oil tamponade was performed, but silicone oil emulsified 22 months later. Due to the widespread necrosis lesions and defects of the peripheral retina, RD was highly likely to reoccur after silicone oil removal; thus, foldable capsular vitreous body was implanted to support the retina. No recurrent RD was observed afterward.

[Ophthalmic Surg Lasers Imaging Retina. 2020;51:653–657.]

Introduction

Acute retinal necrosis (ARN) syndrome is a devastating intraocular inflammatory disease. It is characterized by anterior uveitis, vitritis, and necrotizing retinitis that rapidly extend posteriorly from the peripheral retina.1 Antiviral treatment, as the most common treatment, has been proven therapeutically effective, but the effectiveness of other adjunctive treatment options, such as prophylactic laser and early vitrectomy, remains unclear.2 Secondary retinal detachment (RD) is a frequent late complication of ARN syndrome. Here, we describe a case of RD following ARN, which was treated with pars plana vitrectomy (PPV), silicone oil tamponade, silicone oil replacement, cataract extraction, and foldable capsular vitreous body (FCVB; Guangzhou Vesber Biotechnology Co. Ltd., Guangzhou, China) implantation successively.

Case Report

A 35-year-old male presented with a 9-day history of vision loss, floaters, and pain in his left eye. Exam at admission revealed best-corrected visual acuity (BCVA) of 20/20 in right eye and 20/40 in the left with normal intraocular pressure (IOP). Slit-lamp examination showed 1+ aqueous cell and mutton-fat keratic precipitates on the endothelium. Funduscopy showed swollen optic disk and retinal arteriolar sheathings, with extensive white-yellowish retinal lesions and hemorrhages in peripheral retina (Figure 1). No abnormality of anterior segment or fundus was found in the right eye.

Swollen optic disk and retinal arteriolar sheathings in the left eye, with extensive white-yellowish retinal lesions and hemorrhages in the peripheral retina.

Figure 1.

Swollen optic disk and retinal arteriolar sheathings in the left eye, with extensive white-yellowish retinal lesions and hemorrhages in the peripheral retina.

Fluorescein fundus angiography of the left eye indicated occlusive retinal vasculitis (Figure 2). An extensive array of laboratory workup revealed that the patient was immunoglobulin M (IgM)- and IgG-positive for herpes simplex virus (HSV) and IgM-negative and IgG-positive for cytomegalovirus (CMV).

Fluorescein fundus angiography showed widespread areas of nonperfusion in peripheral retina, which indicated occlusive retinal vasculitis.

Figure 2.

Fluorescein fundus angiography showed widespread areas of nonperfusion in peripheral retina, which indicated occlusive retinal vasculitis.

A diagnosis of unilateral ARN was made and was treated with intravenous acyclovir (10 mg/kg at every 8 hours), corticosteroids (oral prednisone 50 mg per day and prednisolone acetate 1% eye drops), intravitreal injection (ganciclovir [Zirgan; Bausch + Lomb, Rochester, NY] 0.8 mg per week), and laser.

In the next month, retinal necrosis in the left eye significantly resolved, but similar lesions were found in the right. The right eye was also diagnosed with ARN and was given intravitreal injection and photocoagulation. After treatment, funduscopic lesions of the right eye gradually improved and remained stable in future follow-up.

At Day 44 of admission, RD was found in the left eye, which was successfully treated with PPV and silicone oil tamponade. In about a year, cataract of the left eye evolved. Due to the widespread necrosis lesions and defects of retina, we performed silicone oil replacement along with cataract extraction to avoid recurrent RD and possible silicone oil emulsification.

About 2 years after the initial presentation, the patient returned with a complaint about eye pain. His BCVA was 20/20 in the right eye and hand movement (HM) in the left. IOPs were 17 mm Hg and 48 mm Hg in the right and left eyes, respectively. Slit-lamp examination of the left eye showed severe flat peripheral anterior chamber, total adhesion of the iris, and lens capsule. Fundal condition was not clear because of the lens posterior capsular opacity. With IOP not able to be satisfactorily controlled, we considered it to be glaucoma secondary to silicone oil emulsification and planned its surgical removal. Proliferative vitreoretinopathy (PVR) was found intraoperatively. Given the severity of PVR, we implanted FCVB with silicone oil injection after epiretinal membrane peeling.

One week after the implantation, BCVA of the left eye was HM and IOP was 9 mm Hg, with normal-depth anterior chamber, dilated pupil, FCVB in place, and attached retina. And his condition remained stable afterwards (Figure 3).

Photographs of the left eye 1 month after the implantation. (A) Normal-depth anterior chamber, dilated pupil, and foldable capsular vitreous body in place. (B) Attached retina, widespread necrosis lesions, and defects in periphery.

Figure 3.

Photographs of the left eye 1 month after the implantation. (A) Normal-depth anterior chamber, dilated pupil, and foldable capsular vitreous body in place. (B) Attached retina, widespread necrosis lesions, and defects in periphery.

Discussion

ARN syndrome was first reported by Japanese researchers in 1971.3 In 1994, the American Uveitis Society4 defined the diagnostic criteria of ARN based on its clinical characteristics: (1) one or more retinal necrosis lesions with discrete borders in periphery; (2) rapid progression without antiviral treatment; (3) circumferential spread; (4) occlusive vasculopathy with arterial involvement; (5) inflammatory reaction in the vitreous and anterior chamber. However, evidence of etiology was not included in the diagnostic criteria until 2015, using polymerase chain reaction (PCR) to detect intraocular fluid.5 With the help of PCR, antibody testing, viral culture, biopsy and immunocytochemistry, evidence suggests that virus such as Varicella-zoster virus, HSV, CMV, and toxoplasmosis may be the infectious agent causing the disease.6

Bilateral disease may appear in up to one-third of patients, and the contralateral involvement often occurs within weeks.7 In the presented case, the disease was unilateral at first, and the patient's right eye was asymptomatic when necrosis foci were found. Therefore, we proposed the importance of dilated funduscopic exam of both eyes, and we believed that the good visual result of the right eye may be explained by the prompt diagnosis and proper and early treatment.

Necrosis lesions may spread even with adequate diagnosis and antiviral treatment, so the incidence of RD in ARN patients is high and it can occur even after the resolution of ARN.8,9 Vitrectomy with silicone oil tamponade is mandatory to achieve retinal reattachment for rhegmatogenous and traction RD with multiple retinal tears after the fulminant type of ARN, but only 23% can successfully reattach.10 PPV can effectively remove virus, necrosis, inflammatory factors, relieve vitreous traction, and create a chance for complete laser photocoagulation. However, researchers found that PVR developed in nearly every patient which resulted in recurrent RD.11 As a result, there are a considerable number of patients that cannot remove silicone oil without risking recurrent RD.

Although intravitreal silicone oil works as an effective endotamponade, complications such as emulsification, cataract, and secondary glaucoma may occur. In the presented case, the patient returned with IOP elevation, which might be caused by emulsified silicone oil migrating into the anterior chamber and obstructing the trabecular meshwork. Silicone oil emulsification is a multifactorial process in which the biochemical properties of silicone oil, endotamponade duration, and ocular inflammation all play roles.12

FCVB was brought to us as a new vitreous substitute to avoid complications caused by silicone oil. The FCVB consists of a thin vitreous-shaped capsule with a tube-valve system (Figure 4). While silicone oil is injected into the capsule to support the retina, the tube-valve system allows control of the IOP.13 Several studies have shown that the FCVB was flexible, effective, and safe as a vitreous substitute after long-term observation. In addition, it was proven to have little effect on the function of the ciliary body, and can effectively prevent eyeball atrophy after implantation.14–17

The foldable capsular vitreous body consists of a thin, vitreous-shaped capsule with a tube-valve system.

Figure 4.

The foldable capsular vitreous body consists of a thin, vitreous-shaped capsule with a tube-valve system.

In this paper, we demonstrate the evolution of an ARN case and how RD was developed even after treatment as the disease processed itself. Additionally, FCVB, a novel vitreous substitute, should be considered as an application for ARN with severe RD or PVR.

References

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Authors

From Shenzhen Aier Eye Hospital, Shenzhen, China (LZ, JL, BQ); Shenzhen Aier Eye Hospital Affiliated to Jinan University, Shenzhen, China (LZ, JL, BQ); Aier School of Ophthalmology, Central South University, Changsha, China (BQ); Shenzhen Eye Hospital, Shenzhen, China (SL); and Guizhou Medical University, Guizhou, China (LZ)..

Supported by Shenzhen Healthcare Research Project (No. SZLY2017027).

The authors report no relevant financial disclosures.

Drs. Zhang and J. Liu contributed equally to this manuscript as co-first authors.

Address correspondence to Bo Qin, MD, PHD, No. 2048 Binhe Avenue, Futian District, Shenzhen, P.R. China; email: qinbozf@126.com.

Received: March 09, 2020
Accepted: September 03, 2020

10.3928/23258160-20201104-09

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