A 53-year-old male who emigrated from Senegal approximately 20 years ago, with a history of phthisical right eye of unclear etiology, presented with 4 days of painless blurry vision and floaters in the left eye. The patient was otherwise healthy with no history of any systemic infection or disease. Review of systems was negative for flashes of light, headache, fever, or other systemic symptoms.
On examination, visual acuity was no light perception in the right eye and 20/60 in the left eye. Intraocular pressures were 2 mm Hg in the right eye and 13 mm Hg in the left eye. Slit lamp examination of the right eye was consistent with a quiet, painless, phthisical eye. Exam of the left eye revealed diffuse conjunctival injection with granulomatous keratic precipitates across the inferior 50% of the cornea and 2+ AC cell. Posterior exam revealed 0.5+ anterior vitreous cell, 3+ posterior vitreous haze, mild disc edema, and multifocal patches of retinal whitening superior and temporal to the arcades, associated with vessel sheathing and rare hemorrhages. A superior pigmented chorioretinal scar with overlying contracted vitreous was noted in the periphery, with no focal overlying vitritis nor adjacent areas of retinal whitening (shown in Fig. 1a). Fluorescein angiography revealed severe occlusive vasculitis (shown in Fig. 1b).
Given the patient's emigration from Senegal, unknown immune status, and pigmented chorioretinal scar, the differential diagnosis included toxoplasma or tuberculosis uveitis and ARN. He underwent a vitreous chamber and AC tap, followed by intravitreal clindamycin and foscarnet injections. He was started systemically on trimethoprim 60 mg/sulfamethoxazole 800 mg twice daily and valacyclovir 2 g three times daily. HIV, syphilis, and tuberculosis testing were negative. PCR of vitreous and AC fluid was positive for HSV-2 and negative for HSV-1, VZV, CMV, and toxoplasma.
Due to the positive PCR results for HSV-2, trimethoprim-sulfamethoxazole was stopped, and the patient was continued on valacyclovir. He received intravitreal foscarnet injections every 3 days for a period of 10 days. Due to worsening vitritis and stable to improving retinal whitening, he was started on 30 mg of oral prednisone daily 8 days after his initial foscarnet injection. The day after his fourth foscarnet injection (14 days after symptom onset), the patient presented with a large retinal tear and focal RD in the area of temporal necrosis (shown in Fig. 2a, b). The patient underwent perfluorooctane-assisted 25-gauge pars plana vitrectomy with temporal retinectomy, extensive 360  endolaser, and intraocular tamponade with silicone oil. Prior to fluid-air exchange and silicone oil injection, a standard 2.4 mg/0.1 mL dose of foscarnet was injected into the balanced salt solution-filled vitreous cavity and incubated for 5 min before washout. Since foscarnet does not need activation, brief incubation is thought to be sufficient for viral inactivation. He was continued on oral valacyclovir and prednisone postoperatively, with an attached retina and best-corrected visual acuity of 20/80+1 five weeks after surgery.