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Traitement de première intention de la rétinite herpétique nécrosante en donnant la priorité à l'examen du statut immunitaire et des facteurs pronostiques de mauvais résultats visuels

The visual prognosis of patients with necrotizing herpetic retinitis is majorly affected by delay in therapeutic management. We reviewed management, treatment, and outcomes of patients with necrotizing herpetic retinitis in our center to propose an algorithm for first-line management of necrotizing herpetic retinitis.

We performed a retrospective evaluation on a series of patients with necrotizing herpetic retinitis at our tertiary center between 2012 and 2021 using demographic, clinical, ophthalmologic, virological, therapeutic, and prognostic characteristics. We classified patients by necrotizing herpetic retinitis type: acute retinal necrosis, progressive outer retinal necrosis, cytomegalovirus retinitis.

We included 41 patients with necrotizing herpetic retinitis: 59% with acute retinal necrosis, 7% with progressive outer retinal necrosis, and 34% with cytomegalovirus retinitis. All patients with cytomegalovirus retinitis and progressive outer retinal necrosis were immunocompromised versus 21% of patients with acute retinal necrosis. Cytomegalovirus infection was found in 14 (34%) patients, varicella zoster virus infection in 14 (34%) patients, herpes simplex virus type 2 infection in 8 (20%) and type 1 infection in 5 (12%) patients. Intravenous antiviral therapy was received by 98% of patients and intravitreal antiviral injections by 90% of patients. The overall complication rate during follow-up was 83% of eyes. Most frequent complications were retinal detachment (33% eyes) and retinal break (29% eyes). Prognostic factors for poor visual outcomes were pre-existing monocular vision among 17% of patients, bilateral necrotizing herpetic retinitis in 17% of patients, posterior pole involvement in 46% of eyes, and involvement of more than 2 retinal quadrants in 46% of eyes. 

The visual prognosis of patients with necrotizing herpetic retinitis remains poor. Prompt investigation of immune status and presence of factors justifying intravitreal antiviral injections must be prioritized to initiate and adapt management while awaiting causative virus confirmation.

Prior diagnosis of both virus or necrotizing herpetic retinitis type is not required for our proposed urgent first-line management of necrotizing herpetic retinitis, thus reducing delay and improving chances of saving vision.