Conclusions

This case suggests that VZV-associated ARN may initially present as an isolated foveal lesion before peripheral necrotizing retinitis becomes visible. Broad inner retinal hyperreflectivity with posterior shadowing is not typical of PAMM when the abnormality is not confined to the middle retinal layers and should prompt consideration of other diagnoses, including viral retinitis.

When a focal foveal white lesion is accompanied by ocular hypertension, keratic precipitates, or increased aqueous flare, herpetic retinitis should remain in the differential diagnosis even when peripheral necrosis is not visible and no perfusion abnormality is detected within the acquired 6 x 6 mm macular OCTA scan. Careful peripheral retinal surveillance, timely intraocular fluid PCR testing, and prompt antiviral therapy are important to limit progression and preserve vision.