Isolated Unilateral Acute Retinal Necrosis Syndrome as the Initial Manifestation of HIV Infection

The posterior segment manifestations are HIV vasculopathy, infectious retinopathy, choroidopathy, and rare neoplasms. HIV vasculopathy has included HIV microangiopathy and large-vessel disease. HIV microangiopathy is the most common manifestation (40% to 60% of cases) of AIDS in developed countries. Usually, HIV microangiopathy develops when the CD4+ cell count is low (less than 100/μL), but most affected patients usually have no ocular symptoms. Manifestations of HIV microangiopathy include cotton-wool spots, retinal hemorrhages, microaneurysm, telangiectatic vessels, and ischemic maculopathy.1,2 Cytomegalovirus (CMV) retinitis is the most common (15% to 40%) cause of infectious retinopathy in AIDS. CMV retinitis and its complications (eg, immune recovery uveitis, retinal detachment) are the most common causes of visual morbidity.1,2 Other infectious retinopathies include toxoplasmic retinitis, necrotizing herpetic retinopathy (eg, acute retinal necrosis syndrome, progressive outer retinal necrosis), and syphilitic retinitis. Infectious choroidopathy includes Pneumocystis jiroveci choroidopathy, cryptococcal choroidoretinopathy, and mycobacterial choroiditis.1,2 Acute retinal necrosis syndrome occurs most commonly in otherwise healthy patients. In general, patients are not immunocompromised or systemically ill.3 However, this syndrome may demonstrate subclinical immune dysfunction.4 Ocular manifestations may be the presenting sign of a systemic infection in an otherwise asymptomatic HIV-positive person.5 Ocular involvement in these cases is varied and can affect almost all structures of the eye. Most of the visually disabling ocular manifestations, particularly those caused by an opportunistic infection, occur in late-stage HIV disease or AIDS, whereas presumed HIV-related asymptomatic ocular lesions occur in the earlier stages.4,5 Although HIV-infected patients may present with an isolated ophthalmic complication as the initial manifestation of their HIV infection without any other sign of opportunistic infection or condition attributed to HIV infection or indicative of a defect in cell-mediated immunity, HIV infection is relatively less commonly diagnosed by ophthalmologists in its initial presentation. We describe a case of isolated unilateral acute retinal necrosis in a patient as the initial manifestation of his HIV infection, and to the best of our knowledge, this phenomenon has not been previously reported. CASE SUMMARY A 30-year-old man presented to our outpatient department with a history of gradual decrease in vision with floaters in the right eye for 1 month. He also had a history of mild pain in his right eye for 2 weeks. There was no history suggestive of adnexal or corneal involvement or of significant dermatological, neurological, or other systemic illness. On ocular examination, the visual acuity in the right eye was limited to perception of light and the projection of rays was inaccurate; the left eye was 6/6 using the Snellen visual acuity chart. Findings from an examination of ocular adnexa and ocular movement of both eyes were normal. The anterior chamber cell of the right eye was 3+ with fresh keratic precipitates in the cornea, and there was also pigment deposition over the anterior capsule. The anterior chamber of the left eye was normal. Right eye direct and left eye consensual pupillary reflex was absent. Left eye direct and right eye consensual pupillary reflex was present. Intraocular pressures in both eyes were normal (12 mm Hg) by Goldman applanation tonometry.