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Year : 2001  |  Volume : 49  |  Issue : 1  |  Page : 56-57

Frosted retinal branch angiitis in an immunocompetent adult due to herpes simplex virus

1 Department of Ophthalmology, Sultan Qaboos University Hospital, Muscat, Oman
2 Department of Ophthalmology, Sultan Qaboos University Hospital, Muscat

Correspondence Address:
Radha Shenoy
Department of Ophthalmology, Sultan Qaboos University Hopsital, PO Box 38, PC 123 Al-Khodh, Muscat
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Source of Support: None, Conflict of Interest: None

PMID: 15887719

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How to cite this article:
Shenoy R, Elagib EM, Al-Siyabi H. Frosted retinal branch angiitis in an immunocompetent adult due to herpes simplex virus. Indian J Ophthalmol 2001;49:56-7

How to cite this URL:
Shenoy R, Elagib EM, Al-Siyabi H. Frosted retinal branch angiitis in an immunocompetent adult due to herpes simplex virus. Indian J Ophthalmol [serial online] 2001 [cited 2023 Dec 2];49:56-7. Available from: https://journals.lww.com/ijo/pages/default.aspx/text.asp?2001/49/1/56/22668

A case of acute severe loss of vision due to perivasculitis typical of frosted retinal branch angiitis due to Herpes simplex virus in an otherwise healthy young Omani lady is presented.

Frosted Retinal Branch Angiitis is a bilateral or unilateral retinal perivasculitis of unknown aetiology occurring in otherwise healthy individuals. [1, 2] Herpes simplex virus has been implicated to cause a wide variety of lesions involving the anterior and posterior segments of the eye. Bilateral chorioretinitis with perivasculitis, haemorrhage, vitritis and a fatal rapidly progressive necrotising retinitis with occlusive vasculopathy have been reported in both immunocompetent as well as immunocompromised individuals due to Herpes simplex. [3, 4] However a frosted branch angiitis type of vasculitis due to Herpes simplex virus is unusual in an immunocompetent patient. To best of our knowledge only one such case has been reported in the English literature.[5]

  Case report Top

A 26-year-old Omani lady presented to the Ophthalmic Emergency Unit, Sultan Qaboos Hospital, Muscat, Oman, in November 1998 with a history of sudden loss of vision in her right eye of one day's duration. This was preceded by fever and headache of four days' duration. Her medical history was otherwise unremarkable. She had delivered a healthy baby by Lower Segment Caesarean Section 2 months prior to this episode.

Examination showed a sick and febrile young female, with temperature of 39° C. The right eye visual acuity was counting fingers at 2 metres (-0.50 DSph/-0.50 DCyl @ 15°) and her left eye vision was 6/36 (-3.50 DSph), not improving with pinhole. She had been wearing spectacles for the past 4 years and the left eye vision was less than the right eye. External examination, ocular motility and intraocular pressure were normal in both eyes. Amsler grid showed a central scotoma in the right eye, but was uncomplimentary for the left eye. Colour vision testing (Ishihara's chart) was normal for both eyes. Fundus examination showed a yellow infiltrate just above the fovea with minimal surrounding retinal oedema in the right eye and a normal fundus in the left eye. There was no vitreous reaction, exudate or haemorrhage. Fundus fluorescein angiography revealed wide spread staining of the vessel walls in both the eyes with minimal leakage of dye [Figure - 1]. There were no capillary drop outs. Her general examination was otherwise normal.

Based on the above findings, she was diagnosed and investigated for vasculitis. The laboratory result showed an elevated erythrocyte sedimentation rate (37 mm/hr) and C reactive protein (496 nmol/litre) (normal 0-94nmol/litre). Blood culture, antibodies to Brucella, Chlamydia, Toxoplasma, Rubella, Cytomegalovirus, Varicella Zoster, and Syphilis were negative. Both Immunoglobulin G and Immunoglobulin M antibodies to Herpes simplex visrus were positive. Serology for Human immunodeficiency virus was negative. Her CD 4 count was 0.9 x 109/1 (normal 0.5-1.3 x 109/1) and CD 8 count was 0.6 x 109/1 (normal 0.3-1.0 x 109/1). Chest X-ray, tuberculin test, magnetic resonance imaging (MRI) of brain and electroencephalography (EEG) were normal. She was treated with acyclovir (10mg/kg bodyweight intravenous infusion) and oral corticosteroids (1mg/kg body weight).

Three days after commencement of treatment, fever and headache subsided. Vision recovered to 6/12 in the right eye and 6/18 in the left eye with refraction. Parenteral acyclovir was replaced by oral acyclovir (800 mg 5 times daily) and systemic corticosteroids were tapered off gradually over a month.

One month later, the best-corrected visual acuity in the right eye was 6/9 and in the left 6/12. Fundus in both the eyes was normal [Figure - 2]. The central scotoma on Amsler grid in the right eye was replaced by multiple paracentral scotomas. Repeat serology for Herpes simplex virus was negative for Immunoglobulin M and positive for Immunoglobulin G.

  Discussion Top

Frosted retinal branch angiitis is a rare clinical entity. Initially reported by Ito et al and later supported by others, it is a bilateral retinal perivasculitis of unknown aetiology occurring in otherwise healthy individuals. It causes acute temporary visual loss, and responds well to systemic corticosteroids.[1-3] Unilateral cases have also been reported, but with no consistent systemic abnormality.[4] While Cytomegalovirus has been found to be the most common causative agent in immunocompromised patients, it has also been found to occur in infections with Epstein Barr virus, and Toxoplasma as well as in non-infectious conditions like Crohn's disease, systemic lupus erythematosis, leukaemias and lymphomas.[6]

Dimitrois et al have reported a 54-year-old lady who presented with fever, arthritis and acute visual loss in her left eye due to perivasculitis simulating frosted branch angiitis involving the superior fundus.[7] There was minimal vitritis and scattered retinal haemorrhages confined to the area of perivasculitis. Her aqueous and blood samples tested positive for Herpes simplex antibodies by polymerase chain reaction.

Our patient also presented with signs of systemic infection including fever and headache. There was acute loss of vision in her right eye due to perivasculitis, detected on fundus fluorescein angiography. There was no vitritis or perivasculitis noted on ophthalmoscopy but only yellow infiltrate with minimal surrounding oedema just above the fovea in her right eye. The presence of Ig M and Ig G antibodies to Herpes simplex virus during the acute phase, the response to systemic acyclovir and corticosteroids, and the disappearance of the Ig M antibodies during the convalescent phase point to Herpes simplex virus as the causative agent. However, it is not clear whether it is a direct infection of the vessel walls by the virus or an antigen-antibody reaction. This case illustrates that Herpes simplex virus should be considered in the differential diagnosis of retinal perivasculitis.

  References Top

Ito Y, Nakano M, Kyu N, Takeushi, M. Frosted branch angiitis in a child. Jpn J Clin Ophthalmol 1976;30:797-803.  Back to cited text no. 1
Watanabe Y, Takeda N, Adachi-Usami E. A case of frosted branch angiitis. Br J Ophthalmol 1987;71:553-58.  Back to cited text no. 2
Kleiner R, Kaplan JH, Shakin JL, Yannuzzi LA, Crosswell HH, Mclean WC. Acute frosted retinal periphlebitis. Am J Ophthalmol 1988;106:27-28.  Back to cited text no. 3
Sugin SL, Henderly DE, Friedman SM, Jampol LM, Doyle JW. Unilateral frosted branch angiitis. Am J Ophthalmol 1991;111:682-85.  Back to cited text no. 4
Yasaga JE, Davis J. Frosted branch angiitis with ocular toxoplasmosis. Arch Ophthalmol 1999;117:1260.  Back to cited text no. 5
Kleiner RC. Frosted branch angiitis: Clinical syndrome or clinical sign? Retina 1997;370-71.  Back to cited text no. 6
Dimitrois M, Panagiotis GT, Michalis NA, Drakoulis N, Markomichelakis NN. Retinal perivasculitis in an immunocompetent patient with systemic Herpes simplex infection. Am J Ophthalmol 1997;123:699-702.  Back to cited text no. 7


  [Figure - 1], [Figure - 2]

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