Posterior pole involvement as the presenting feature of varicella zoster virus- associated acute retinal necrosis in a young healthy man

Purpose: To report on the long-term clinical course of a young, healthy patient who presented with a solitary posterior pole lesion as the initial manifestation of acute retinal necrosis (ARN). Methods: Descriptive case report. Results: A 37-year-old man presented with a two-day history of right eye redness, pain and central scotoma. Examination revealed panuveitis and a solitary whitish-yellow retinal infiltrate in the posterior pole, with an otherwise normal retinal periphery. Given the clinical suspicion of Bartonella-associated retinitis, empiric systemic antibiotic therapy was initiated. One week later, new peripheral whitish-yellow retinal infiltrates emerged. Anterior chamber tap was positive for varicella zoster virus (VZV). The patient was diagnosed with acute retinal necrosis (ARN). Systemic and intravitreal antiviral therapy was initiated in combination with prednisone. All retinal lesions regressed completely. Areas of macular and peripheral retinal atrophy subsequently developed. At one-year of follow-up, visual acuity improved significantly from logMAR 1.0 to 0, with no disease recurrence or additional complications. Conclusions: Posterior pole involvement as the initial manifestation of ARN in immunocompetent individuals is uncommon. This case highlights the importance of recognizing atypical clinical phenotypes of ARN. While the intensive medical therapy did not prevent the loss of retinal tissue, it successfully halted the progression of the infection toward the fovea, thereby allowing the preservation of excellent final visual acuity. Although uncommon, macular involvement should be included in the differential diagnosis of viral retinopathies. Prompt diagnosis and appropriate antiviral therapy are critical to preserving visual function and preventing further complications.