key: cord-0956235-rahkzvis authors: Sarpangala, Shailaja; George, Neenu M; Kamath, Yogish S; Kulkarni, Chidanand title: Central retinal vein occlusion secondary to varicella zoster retinal vasculitis in an immunocompetent individual during the COVID-19 pandemic - A case report date: 2021-08-25 journal: Indian J Ophthalmol DOI: 10.4103/ijo.ijo_1644_21 sha: c3c17b367ae480d433bfe50680643f57c5588040 doc_id: 956235 cord_uid: rahkzvis We report the occurrence of unilateral central retinal vein occlusion (CRVO) in a young yoga enthusiast who presented amidst the COVID-19 pandemic. Subtle signs of uveitis when systemically investigated revealed a multitude of causes, but ocular fluid polymerase chain reaction was positive for varicella zoster virus (VZV). The prompt initiation of antivirals resulted in a good visual outcome. Our case describes the rare presentation of VZV retinal vasculitis as CRVO in a young healthy individual and highlights the importance of early antiviral therapy for favorable outcomes. Ocular infection with varicella zoster virus (VZV) can have a varied presentation ranging from herpes zoster ophthalmicus to acute retinal necrosis (ARN) and progressive outer retinal necrosis. [1] Central Retinal Vein Occlusion (CRVO) secondary to VZV is rare, with reports of occurrence in an individual with HIV infection [2] and in elderly people with cardiovascular morbidity. [3] It has also been reported in association with varicella zoster dermatitis. [4, 5] We describe the case of a young immunocompetent male who presented with features of CRVO but was detected to have an underlying retinal vasculitis due to VZV. A 23-year-old male from coastal Karnataka was referred as a case of CRVO in November 2020. He presented with a history of sudden onset rapidly worsening painless loss of vision in the right eye (RE) for 3 days. He denied a history of fever or skin An aqueous humor sample from the RE sent for polymerase chain reaction (PCR) [TaqMan Real-Time PCR probe] analysis was positive for VZV. Oral valacyclovir 1 gm thrice a day was initiated, with clinical improvement being noted in 3 days [ Fig. 1c ]. Subsequent therapy with oral prednisolone 60 mg once a day, topical ciprofloxacin (0.3% w/v), and dexamethasone (0.1% w/v) in tapering doses resulted in further improvement of signs, including a resolution of macular edema with the appearance of a macular star. After a total of 6 weeks of antiviral and steroid therapy, his best-corrected vision in the RE improved to 6/6, N6 with marked improvement in fundus findings, and was maintained till 3 months of follow-up [ Fig. 1d ]. Our case presented a diagnostic dilemma with an unusual clinical picture and lab diagnoses. In the general healthy population, CRVO is more common than ARN. [6, 7] Hence, CRVO secondary to vasculitis due to viral retinitis may be easily missed in early cases. Moreover, with CRVO being described in patients performing yoga and in COVID-19 infection, other treatable infective causes are likely to be overlooked. Shah et al. [8] reported a case of central retinal vein occlusion following sirsasana, also called the "headstand" posture in yoga, which was regularly performed by our patient. However, unlike their report, the younger age, absence of history of previous thromboembolic phenomenon, and systemic co-morbid illnesses made this diagnosis less likely in him. The presentation in the backdrop of the prevailing pandemic also suggested the possibility of retinal vein occlusion due to COVID-19 itself. [9] Our patient had denied any clinical symptoms or contact with an infected case to warrant the need for investigation of COVID-19, which was bound by regulatory guidelines. However, subclinical SARS-CoV2 infection has been implicated in cases of Herpes zoster appearing during the pandemic. [10] Among the inflammatory causes, Toxoplasmosis is a common cause of posterior uveitis in the young. Although serology revealed toxoplasma IgG to be positive, there was no evidence of active or old chorioretinitis suggestive of toxoplasmosis. Sarcoidosis is another important cause of retinal vasculitis. However, in our case, the absence of peripheral exudative vasculitis and choroiditis made the diagnosis less likely despite a raised serumACE. Apart from the predominantly hemorrhagic form of vascular sheathing and an acute presentation, there were almost no clinically evident signs pointing toward Varicella zoster infection. The subtle OCT features of retinitis and the positive VZV DNA in PCR made it the most likely etiology. As vascular occlusion may precede ARN, [3] antiviral therapy was the first line of management implemented. The favorable outcome of this early intervention further substantiates our diagnosis. Oral valaciclovir 1000 mg 8 th hourly was started based on reports of its efficacy being nearly equal to intravenous acyclovir therapy in the treatment of ARN. [11] Varicella zoster has been implicated as a cause of CRVO due to retinitis, retinal vasculitis, and optic perineuritis [ Table 1 ]. Our case had a better visual outcome than the other described cases, probably due to isolated central retinal venous occlusion, without arterial involvement. Early identification of the causative organism, younger age of presentation, absence of comorbidities, and early initiation of antiviral therapy may also have contributed to the better outcome. CRVO may be the initial presentation of varicella zoster-induced retinal vasculitis in a young immunocompetent individual. A strong clinical suspicion aided by ocular fluid analysis and early initiation of antiviral therapy can prevent progression to sight-threatening complications such as ARN. The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Nil. Persistent dilemmas in zoster eye disease Central retinal vein occlusion due to herpes zoster as the initial presenting sign in a patient with acquired immunodeficiency syndrome (AIDS) Central retinal vascular occlusion associated with acute retinal necrosis Optic neuropathy and central retinal vascular obstruction as initial manifestations of acute retinal necrosis Combined central retinal artery and vein occlusion with optic perineuritis following herpes zoster dermatitis in an immunocompetent child The burden of disease of retinal vein occlusion: Review of the literature Acute retinal necrosis: A national population-based study to assess the incidence, methods of diagnosis, treatment strategies and outcomes in the UK Central retinal vein occlusion following Sirsasana (headstand posture) Retinal vein occlusion in COVID-19: A novel entity Herpes zoster might be an indicator for latent COVID-19 infection Treatment of acute retinal necrosis syndrome with oral antiviral medications Adult with chickenpox complicated by systemic vasculitis and bilateral retinal vasculitis with retinal vascular occlusions There are no conflicts of interest.