Necrotising retinitis in nasal periphery

CASE REPORT A 39-year-old woman presented in November 1994 to the Accident and Emergency Department of the Birmingham and Midland Eye Hospital with a recent onset of a shadow and floaters in the temporal field of her vision of her left eye. She had previously attended in October 1993 with an unusual appearance of the temporal periphery of the right retina. This lesion was thought to be a retinoschisis and was adjacent to a region of chorioretinal atrophy. There was no evidence of inflammation in the vitreous or retina. The schisis was observed but a retinal detachment subsequently occurred and she underwent a vitrectomy in September 1994 following failure of conventional detachment surgery. A devastating Haemophilus influenzae endophthalmitis developed 3 days after surgery. Despite treatment with systemic and intravitreal antibiotics, and prednisolone 60 mg per day the eye became blind and phthisical. The corticosteroid dose was gradually reduced to 15 mg over the next 2 weeks. She was a severe asthmatic who had suffered from recurrent bouts oflower respiratory tract infection and had been on systemic prednisolone continuously for the last 17 years. She had undergone many acute admissions to hospital for her asthma, necessitating short term increases in her corticosteroid therapy. This was gradually reduced to a maintenance dose of 5 mg per day. She presented to us 2 months after the episode of endophthalmitis affecting her right eye and was still on oral prednisolone 15 mg per day. She had active cold sores on her lips and in her left nostril. She did not appear malnourished. Visual acuity was 6/9 in the left eye. There was a mild anterior uveitis, with a 1 + cells in the anterior chamber and fine keratic precipitates on the inferior cornea. There was 1+ of cells in the vitreous. Ophthalmoscopic examination showed a small, circumferential white area in the inferonasal periphery of the retina associated with sheathing of retinal arterioles and scattered haemorrhages (Fig 1). The lesion in the nasal periphery of her left retina slowly progressed and a provisional diagnosis of acute retinal necrosis was made. Treatment with intravenous acyclovir, 10 mg/kg three times a day, was given and indirect laser photocoagulation applied around the lesion.