![]() Hans Journal of Ophthalmology 眼科学, 2013, 2, 23-26 http://dx.doi.org/10.12677/hjo.2013.23005 Published Online September 2013 (http://www.hanspub.org/journal/hjo.html) Pediatric Acute Retinal Necrosis—A Case Report Chiu-Tung Chuang, Tsung-Tien Wu, Ming-Ying Chu, Shwu-Jiuan Sheu Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung Email: ctchuang@vghks.gov.tw Received: Jul. 11th, 2013; revised: Aug. 10th, 2013; accepted: Aug. 18th, 2013 Copyright © 2013 Chiu-Tung Chuang et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract: Purpose: To report an uncommon case of acute retinal necrosis in a 5-year-old girl. Methods: Case report. Results: A 5-year-old girl presented with redness, ocular pain and blurred vision present for few days on the right eye. The past medical history revealed herpetic encephalitis at the age of 1. On examination, visual acuity was 6/60 on the right and 6/6 on the left. Slit-lamp examination showed moderate anterior uveitis and vitritis in her right eye. Fundo- scopy showed large areas of peripheral circumferential retinal necrosis. Under the diagnosis of acute retinal necrosis due to its typical fundus lesions, treatment with intravenous Acyclovir and topical steroid eyedrops were started imme- diately. Pediatric examination and laboratory testing, including immunologic tests, were normal. After 10 days, treat- ment was changed to oral Valaciclovir and Prednisolone. Topical treatment was tapered gradually. The response was well initially, with resolution of retinitis patches and improvement of visual acuity to 6/20 in 3 weeks. Oral steroids were gradually reduced, and original lesions completely disappeared in 4 weeks, leaving only retinal pigment epithelial change. Seven weeks later, vision dropped to counting finger on the right due to rhegmatogeous retinal detachment. Conclusion: We report an uncommon case of acute retinal necrosis in a 5-year-old girl. This patient responded well to systemic antiviral medication and steroid initially but developed rhegmatogeous retinal detachment 7 weeks later. Keywords: Acute Retinal Necrosis; Polymerase Chain Reaction; Prophylactic Vitrectomy 幼儿急性视网膜坏死之病例报告 庄秋同,吴宗典,朱明嫈,许淑娟 高雄荣民总医院眼科部,高雄 Email: ctchuang@vghks.gov.tw 收稿日期:2013 年7月11日;修回日期:2013 年8月10 日;录用日期:2013 年8月18 日 摘 要:目的:报告一个 5岁女童罹患急性视网膜坏死之少见病例。方法:病例报告。结果:一名 5岁女童因 多日前突发性右眼红痛及视力模糊而求诊,病患于 1岁时曾有疱疹病毒性脑炎之病史。眼科理学检查发现右眼 视力为 0.1,左眼为1.0。裂隙灯检查发现右眼前房及玻璃体皆有中度炎症反应,视网膜周边则出现坏死性区域。 由于其典型之眼底病灶,故诊断为急性视网膜坏死,并开始给予静脉注射Acyclovir 及类固醇眼药水治疗。儿科 检查和实验室测试,包括免疫测试,都是正常的。十天后改为口服Valaciclovir 并加上口服类固醇治疗。药效初 期反应良好,三星期后视网膜坏死区域已减少,患眼视力也进步至0.3;口服类固醇逐步减量,原先之病灶于 4 星期后皆已消失,仅留下视网膜色素层变化,但于治疗 7星期后倂发裂孔性视网膜剥离。结论:我们报告一例 急性视网膜坏死发生于 5岁女童之少见病例,病患经全身性抗病毒药物合倂口服类固醇治疗后一度恢复良好, 但于治疗7星期后倂发裂孔性视网膜剥离。 关键词:急性视网膜坏死;聚合酶连锁反应;预防性玻璃体切除 Copyright © 2013 Hanspub 23 ![]() 幼儿急性视网膜坏死之病例报告 Copyright © 2013 Hanspub 24 1. 引言 时一次)治疗。十天后改为口服抗病毒药物Valaciclovir (400 mg 每天3次)并加上口服类固醇 Prednisolone (每 天15 mg)治疗。经全身性抗病毒药物合倂口服类固醇 治疗后,药效初期反应良好,三星期后视网膜坏死区 域已减少,患眼视力也进步至 0.3;之后口服类固醇 逐步减量,原先之病灶于 4星期后皆已消失,仅留下 视网膜色素性变化(图2),但于治疗7星期后,病患视 力突然急遽下降至眼前数指三十公分,经检查发现倂 发裂孔性视网膜剥离(图3)。虽已帮病患安排玻璃体切 除合并硅油填充手术,但病患并未回诊就医。 急性视网膜坏死(Acute retinal necrosis, ARN) 最 早是由日本学者Uruyama 于1971 年所提出[1]。ARN 的病征包含有周边视网膜的坏死、阻塞性血管炎、虹 彩炎及玻璃体炎等[2]。这个疾病大部份发生在成人, 儿童并不常见[3],故我们于此报告一例发生于5岁女 童之少见病例。 2. 病例报告 病患为一名5岁女童,因多日前突发性右眼红痛 及视力模糊而求诊。病患于 1岁时曾有疱疹病毒性脑 炎之病史,但并无残留之后遗症。眼科理学检查发现 右眼视力为0.1,左眼为 1.0,双眼眼压正常。右眼前 房及玻璃体皆有中度炎症反应,视网膜周边则出现黄 白色坏死区域(图1)。小儿科会诊、血液常规、胸部 X 光、免疫学及感染性致病源之血清检查并无特别发 现。由于其典型之眼底病灶,故诊断为急性视网膜坏 死,并开始给予静脉注射抗病毒药物 Acyclovir (200 mg 每天 3次)及类固醇眼药水1% Pred-Forte (每4小 3. 讨论 ARN是由疱疹病毒家族的部份病毒所引起;其中 水痘带状疱疹病毒(Varicella zoster virus, VZV)占大多 数[4],单纯性疱疹第一型(Herpes simplex virus type 1, HSV-1)及第二型(HSV-2)次之,而巨细胞病毒 (Cytomegalovirus, CMV)及伊波病毒(Epstein-Bar virus, EBV)则相当罕见。Ganatra 曾报告由 VZV 及HSV-1 引起的 ARN 患者通常年龄在25 岁以上,而 (a) (a) (b) (b) Figure 2. Resolution of peripheral retinal necrosis after treatment for 4 weeks (a) temporal part (b) inferior part Figure 1. Confluent peripheral retinal necrosis (a) temporal pa rt (b) inferior part 图2. 原先之病灶于 4星期后皆已消失,仅留下视网膜色素性变化 (a)颞侧(b)下方 图1. 视网膜周边出现黄白色坏死区域(a)颞侧(b)下方 ![]() 幼儿急性视网膜坏死之病例报告 (a) (b) Figure 3. Rhegmatogenous retinal detachment developed after treatment for 7 weeks (a) posterior part (b) inferior part 图3. 7星期后倂发裂孔性视网膜剥离(a)后极部(b)下方 HSV-2 引起者则在25 岁以下;若曾有中枢神经系统 感染之病史,则单纯性疱疹病毒极可能为其致病原因 [5]。本例患者过去曾有疱疹病毒性脑炎之病史,但可 惜未做病毒学方面的检查,无法再次验证这一发现。 ARN的诊断主要是依据临床表征及病程,然而一 些非典型表现之病患则需进一步检查,以免延误治 疗。传统的病毒培养法既耗时又易有伪阴性,故聚合 酶连锁反应(polymerase chain reaction, PCR)是最佳的 检查工具;根据之前的研究报告,PCR 的灵敏度可高 达90%[5,6]。 ARN药物治疗的主要目的是尽快让患眼复原,同 时避免对侧眼受到侵犯,由于大多数的 ARN 是VZV 或HSV 所引起,故静脉注射Acyclovir是治疗首选, 建议剂量为静脉注射 Acyclovir (5~10 mg/kg每天3次) 7至10 天,之后改成口服Valaciclovir (1 g 每天 3次)1 至3个月。然近来也有使用玻璃体内注射抗病毒药物 作为辅助疗法[7,8] ,或仅使用口服 Valaciclovir 或 Famciclovir 成功治疗之报告[9,10]。全身性类固醇可以 减少眼内发炎及恢复玻璃体清澈,但需于抗病毒药物 开始使用后方可给予,初始剂量为每天每公斤 1~2 毫 克,之后逐步减量,而局部类固醇眼药水则用于眼前 段发炎之患者。有些学者亦建议使用抗凝血剂来减低 血管阻塞的并发症[11] ,但并未有临床试验证实其效 果。 视网膜剥离是 ARN最严重的后遗症之一,也是 造成视力丧失的主因,发生率可高达 75%,有学 者提 出施以预防性雷射于病变处后缘,并指出可使视网膜 剥离发生率有效降低[8,12];但亦有报告指出预防性 雷 射其实效果不佳[13],因其样本数通常太小,而适合接 受雷射治疗者通常是玻璃体清澈病情较轻微者,故易 有统计上的偏差[14]。近来有一些施行预防性玻璃体切 除以避免视网膜剥离发生的报告[14,15],其作用主要是 消除玻璃体对视网膜牵扯的力量,虽然于减少发生率 部份确实让人振奋,但是最终视力却没有明显改善 [14,16],或许视网膜剥离前已有视网膜缺血或视神经萎 缩是可能之原因。本例患者因年纪小而无法配合预防 性雷射之施行,于发生视网膜剥离后又未回诊接受手 术治疗,故无法评估其视力预后,甚感可惜。我们之 前曾有两例急性视网膜坏死发生视网膜剥离的成人 病例,经玻璃体切除及硅油填充后视网膜皆复位良 好,术后最佳矫正视力为 0.1,或可作为视力预后之 参考。 4. 结论 我们报告一例急性视网膜坏死发生于 5岁女童之 少见病例,病患经全身性抗病毒药物合倂口服类固醇 治疗后一度恢复良好,但于治疗 7星期后倂发裂孔性 视网膜剥离。急性视网膜坏死病患发生视网膜剥离的 机率甚高,目前预防视网膜剥离的预防性处置有二: 一是于视网膜坏死处后缘做预防性雷射,另一则是施 行预防性玻璃体切除;本例患者因年纪小而无法配合 预防性雷射之施行,故若早期进行预防性玻璃体切除 或许可以预防其视网膜剥离发生。 参考文献 (References) [1] A. 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