Acute Retinal Necrosis Presenting with an Initial Foveal Lesion: The Importance of Early Diagnosis and Therapeutic Intervention Using OCT and Aqueous Humor PCR

Purpose: To report a rare case of varicella-zoster virus (VZV)–associated acute retinal necrosis (ARN) in which a foveal lesion was the initial manifestation, preceding the development of peripheral necrotizing retinitis, and to highlight early diagnostic clues before typical peripheral findings emerge. Design: A case report. Methods: The clinical course, multimodal imaging findings, and treatment response of a patient with foveal-onset ARN were retrospectively reviewed. Results: A 63-year-old immunocompetent man presented with decreased vision and elevated intraocular pressure in the left eye. Optical coherence tomography revealed hyperreflective changes predominantly in the inner retinal layers with disruption of the ellipsoid zone (EZ) at the fovea. Initial fundus examination and fluorescein angiography showed no peripheral retinal lesions, retinal vasculitis, or vascular occlusion. Subtle anterior chamber inflammation with keratic precipitates was present. Four days later, peripheral necrotizing retinitis developed, and aqueous humor polymerase chain reaction testing was positive for VZV DNA. Intravenous acyclovir and systemic corticosteroids were initiated, resulting in regression of retinal lesions, partial restoration of outer retinal structures, and preservation of visual acuity without retinal detachment. Conclusions: Foveal-onset ARN can initially present with elevated intraocular pressure, inner retinal hyperreflectivity on OCT, and absence of peripheral lesions or angiographic vasculitis, as observed in the present case. Recognizing this atypical presentation should prompt early aqueous humor PCR testing and timely antiviral therapy to prevent progression and preserve visual function.