Acute Retinal Necrosis with Choroidal Inflammation, Optic Perineuritis, and Early Retinal Detachment: A Case Report

Introduction: This is a retrospective case report of atypical acute retinal necrosis (ARN), describing a rare presentation of ARN in an immunocompetent adult, with choroidal, optic nerve, and orbital inflammation with exudative retinal detachment (ERD), complicated by early rhegmatogenous retinal detachment (RRD). Case report: Examination revealed right eye granulomatous panuveitis, including granulomatous anterior chamber inflammation, dense vitreous haze, and peripheral necrotizing hemorrhagic retinitis. Optical coherence tomography (OCT) showed inner retinal hyperreflectivity, thickened choroid, and ERD. Magnetic resonance imaging (MRI) confirmed inflammation of the optic nerve sheath and orbital tissues. Polymerase chain reaction (PCR) confirmed varicella-zoster virus (VZV) infection. Left eye showed an old peripheral chorioretinal scar. Patient received systemic acyclovir, oral trimethoprim-sulfamethoxazole, along with systemic corticosteroids and intravitreal ganciclovir. Final resolution of ERD and improvement in orbital and intraocular inflammation were observed. The patient subsequently developed early RRD, managed by pars plana vitrectomy (PPV) and silicone oil tamponade. Despite structural stabilization, visual recovery was limited due to late presentation, optic nerve, and choroidal involvement. Systemic investigations excluded alternative causes. Conclusions: ARN with concurrent panocular inflammation, choroidal, and optic nerve involvement is uncommon and may indicate a more aggressive disease course, often associated with poor visual prognosis. This case highlights that ARN with choroidal and optic nerve involvement may follow an aggressive course, requiring early PCR confirmation, intensive antiviral therapy, and timely surgical intervention to prevent severe visual loss