Sequential multimodal imaging of varicella-zoster virus-associated acute retinal necrosis: Insights supporting a neurotropic hypothesis

PurposeTo characterise the sequential macular changes using spectral-domain optical coherence tomography (SD-OCT) in acute retinal necrosis (ARN) and compare these with the von Szily model of neuronally transmitted herpetic retinitis.MethodsSingle-patient case study with serial SD-OCT imaging and analysis of aqueous humour varicella zoster virus (VZV) levels.ResultsA 30-year-old immunocompetent woman presented with 360° confluent peripheral retinal necrosis and scattered multifocal lesions in the right eye. VZV DNA was detected in the aqueous humour by polymerase chain reaction (PCR). At baseline, multiple radial retinal folds around the fovea were visible, appearing as sharp inner retinal undulations on SD-OCT. Numerous continuous and beaded vertical hyperreflective strips (VHRS) were present within the outer nuclear layer; in the parafovea, these followed the oblique course of the Henle fibre layer. By days 4-5, neurosensory detachments developed beneath VHRS, with subfoveal choroidal thickness peaking at day 9. Despite systemic and intravitreal antivirals, the right eye deteriorated to light perception, hypotony, and phthisis.ConclusionSequential macular SD-OCT in VZV-associated ARN revealed inner retinal undulations and vertical hyperreflective strips in the outer nuclear layer preceding neurosensory detachments. These observations may correspond to viral dissemination along neuronal pathways from the inner to outer retina, consistent with mechanisms described in animal models. Recognition of these imaging biomarkers could support early detection of macular involvement and improve understanding of ARN pathogenesis in humans.