Introduction

Acute retinal necrosis (ARN) is a sight-threatening necrotizing herpetic retinitis that most often occurs in individuals without recognized immunodeficiency. The classic clinical criteria proposed by the American Uveitis Society emphasize one or more well-demarcated areas of peripheral retinal necrosis, rapid progression without antiviral therapy, circumferential spread, occlusive retinal vasculopathy, and prominent intraocular inflammation [1]. More recently, the Standardization of Uveitis Nomenclature (SUN) Working Group proposed classification criteria incorporating peripheral necrotizing retinitis together with virologic or characteristic clinical evidence [2]. Delayed recognition and treatment increase the risk of severe visual loss and rhegmatogenous retinal detachment; therefore, prompt antiviral therapy is essential [3].

Although Varicella-zoster virus (VZV)-associated ARN is well characterized, posterior pole or macular involvement may occasionally precede the typical peripheral findings [4-9]. Such cases are difficult to diagnose because a solitary macular white lesion can initially suggest an ischemic or inflammatory maculopathy. Classic paracentral acute middle maculopathy (PAMM), however, is characterized on optical coherence tomography (OCT) by a band-like hyperreflective lesion centered at the outer plexiform layer and inner nuclear layer, followed by thinning of the inner nuclear layer [10]. We report a case in which the earliest documented lesion was centered on the fovea and the subsequent broad retinal hyperreflectivity and accompanying inflammatory signs were more consistent with early necrotizing viral retinitis than with PAMM.

An earlier version of this case report was posted as a preprint on Research Square [11]. The present manuscript has been substantially revised, particularly with regard to the interpretation of the initial OCT findings and the clinical significance of the foveal-onset presentation.