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Objective:To invesigate the manifestations, treatment principles and the value of application of etiological research in clinical treatment associated with acute retinal necrosis (ARN).Methods:There are two groups:the experimental group of ARN, and the control group of PVR.Thirty eight ARN patients (44 eyes) were recruited from Jan.1996 to May 2009 in PUMCH. The routine eye examinations were taken for all group members:visual acuity, the anterior segment examination with slit lamp microscope, fundus mydriasis examination and FFA. In accordance with epidemiology characteritic, all patients were given ACV or GCV for systemic anti-viral therapy, and GCV was administrated sysmatically by to 24 eyes, and 29 eyes were underwent vitrectomy.38 patients were drawn blood for TORCH test before the surgery,21 patients underwent test of serum total IgG.18 eyes (18 patients) were detected the total IgG and the TORCH of the vitreous humor samples before vitrectomy or GCV intravitreal injection.1 eye (no light perception) was taken chorioretinal biopsy during the process of Vitrectomy and was detected the Virus DNA through PCR.The control group:15 PVR patients (15 eyes) from June 2006 to Nov.2008 in PUMCH. The routine eye examinations were taken for all group members:visual acuity, the anterior segment examination with slit lamp microscope, fundus examinations with papillary.15 eyes underwent vitrectomy surgery, and during the process of operation, venous blood was drawn to test the total IgG and the TORCH test respectively.SPSS 16.0 statistical software was used to calculate the geometric mean of virus-specific antibody titers, analyze of the variance of data. All data is expressed by average±standard deviation. Based on statistical theory, if the survey result of P<0.01, then the statistics is statistically significant. Therefore, we can determine ARN pathogens by calculating Goldmann-Witmer C according to the data of vitreous humor virus-specific antibody test. Results:In the 38 ARN patients (44 eyes), there were 9 eyes (9 patients) in the acute stage, and 10 eyes (10 patients) in the remission stage, and 25 eyes (22 patients) in the advanced stage.The baseline visual acuity of the first visit,6 eyes (13.6%) were 0.3-1.0, and 12 eyes (27.3%) were 0.1-0.3, and 2 eyes (4.5%) were 0.05-0.1, and1 eye (2.3%) were 0.02-0.05,19 eye (43.2%) were light perception-0.02, and 4 eyes (9.1%) were no light perception. In The intraocular pressure of the first visit:10 eyes (22.7%) were 0-9mmHg, and 28 eyes (63.6%) were 10-22mmHg intraocular pressure, and 6 eyes (13.6%) were 23-40mmHg intraocular pressure. Meanwhile,37 eyes were mixed or ciliary injection of conjunctiva, and 25 eyes (56.8%) had the KP, and 11 eyes (25.0%) had the pigmented KP, and 29 eyes (65.9%) had aqueous flare(+-++) and floating body (+-+++).44 eyes suffered from varying degrees of vitreous opacity and dust-like or flocculent.2 eyes could not be glimpsed into the fundus.10 eyes (22.7%) had Optic nerve congestion and edema.36 eyes (81.8%) had retina multiple, focal or confluent yellow-white necrotic lesions.10 eyes (22.7%) had retinal points, flake haemorrhage.22 eyes (50.0%) had arterial sheath or showed a white linear nodular changes.4 eyes (9.0%) had macular edema. 1 eye (2.3%) had macular epiretinal membrane.10 eyes (22.7%) had Peripheral retinal pigmentation.23 eyes (52.3%) had retinal detachment.13 eyes (13 patients) underwent FFA examination, and 10 eyes showed an early disc telangiectasia and had Fluorescence leakage during angiography.8 eyes had the slim retinal artery, and some small arteries were filled slowly or showed a segmental filling. The early retinal necrosis area showed a weak fluorescence, and the late retinal necrosis area showed fluorescent dye and a high fluorescence.5 eyes had macular telangiectasia, and in the advanced stage, had petal-like fluorescence accumulated.In the 38 ARN patients (44 eyes), they were all treated with systemic anti-viral treatment. According to ARN age of onset of the epidemiological characteristics, the young group had 11 patients (12 eyes) and the age was from 31.09±7.63. They were considered for HSV infection, and the first choice of treatments was acyclovir. The old age group had 27 patients (32 eyes) and the age was from 48.22±7.08. They were considered for VZV infection, GCV was dripped into venous. After treatment, an anterior segment inflammation disappeared, retinal necrosis subsided, and the retina was in place.24 eyes (22 patients) were implemented the GCV intravitreal injection due to their fundus diseases deteriorated continuously. The dose of injection was 200-400μg per time, and the average of injections was 2.08±1.35 times. After the injection,9 eyes were found that the anterior segment inflammation disappeared, and fundus lesions subsided and visual acuity was improved significantly.3 eyes were found the anterior segment inflammation disappeared, and vitreous opacities reduced significantly and fundus lesions subsided.12 eyes had a worse situation and a heavier vitreous opacity, so vitrectomy was implemented.In the 38 ARN patients (44 eyes),28 eyes (25 patients) had retinal detachment with PVR, including:25 eyes had retinal detachment with PVR in the first diagnosis,3 eyes deteriorated and had retinal detachment with PVR during the treatment. The rate of retinal detachment was 63.2%.23 eyes out of 28 eyes underwent vitrectomy, including 21 eyes were taken vitreous surgery combined with Silicone oil temponade, and the retina recovered attachment. The recovery rate was 95.2%. In the 28 eyes,2 eyes were taken vitreous surgery combined with C3F8 filling, and 1 eye’s (50%) retina wasn’t in place after the operation. The recovery rate was 50.0%. The second Vitreous surgery combined with Silicone oil filling was implemented, and the retina was in place after the operation. Meanwhile, in the 28 eyes,5 eyes were not implemented the related operations due to the patients’choice and their retinas did not recover.In the 38 ARN patients (44 eyes), other 7 eyes were taken vitrectomy due to heavy Vitreous opacities, including:3 eyes were just implemented vitrectomy,1 eye was taken Vitreous surgery combined with C3F8 filling, and 3 eyes were taken Vitreous surgery combined with Silicone oil filling. After surgery,6 eyes’vitreous opacities disappeared and retinas were in place.1 eye had retinal detachment with PVR, so it was taken the second Vitreous surgery combined with Silicone oil filling, and the retina recovered after the operation.After the treatment, the visual acuity of patients was:13 eyes (29.5%) had the visual acuity of 0.3-1.0, and 5 eyes (11.4%) had the visual acuity of 0.1-0.3, and 1 eye (2.3%) had the visual acuity of 0.05-0.1 , and 1 eye (2.3%) had the visual acuity of 0.02-0.05, and 20 eyes (45.5%) had the visual acuity of Light perception-0.02, and 4 eyes (9.1%) had no light perception. The patients’latest intraocular pressure was:5 eyes (11.4%) had the intraocular pressure of 0-9mmHg and 38 eyes (86.4%) had 10-22mmHg and 1 eye (2.2%) had 23-30mmHg. Moreover,25 eyes’(25 patients) aqueous flare and floating body disappeared or significantly decreased.9 eyes’(9 patients) gray KP decreased, but visible pigment KP was still there.4 eyes (3 patients) had no change on gray KP and Floating body behind Cornea.14 eyes’(14 patients) vitreous was transparent and 25 eyes’ (23 patients) vitreous opacity disappeared or decreased significantly.38 eyes’(36 patients) yellow-white lesions on Retina were faded,3 eyes’on retina were absorbed and had pigmentation.20 eyes’(19 patients) retinas were in place, and 6 eyes’(4 patients) retinas were not recovered.In the first diagnosis of PVR group (control group), the pre-treatment visual acuities of 15 patients (15 eyes) were:1 eye (6.7%) had the visual acuity of 0.1-0.3,1 eye (6.7%) had 0.05-0.1,3 eyes (20.0%) had 0.02-0.05,10 eyes (66.7%) had the visual acuity of Light perception-0.02. In the first diagnosis,8 eyes (53.3%) had the lower intraocular pressure than 10mmHg,7 eyes (46.7%) had 10-21mmHg,6 eyes (13.6%) had 23 40mmHg.9 eyes (9 patients) had a gray or brown KP.8 eyes had wedge-shaped and nuclear cataract opacities.3 eyes were intraocular lens.1 eye was aphakia.3 eyes had different degrees of pigment granules turbidity in vitreous.7 eyes had liquefaction and turbidity in vitreous, and whose fundus was high myopia fundus like Leopard and appeared large shrinkage of plaque.15 eyes had the retina detachment with PVR.15 eyes were implemented vitrectomy, including:2 eyes were implemented sclera outer ring ligation procedure, and 3 eyes were implemented intraocular lens removal surgery and post-cataract surgery, and 8 eyes were implemented Lens resection.14 eyes were implemented silicone oil filling into vitreous cavity, and respectively, were removed silicone oil after 3 to 5 months.1 eye among them was implemented vitrectomy combined inert gas C3F8 tamponade after silicone oil out. In the latest diagnosis,3 eyes (20%) had the visual acuity of 0.3-1.0, and 3 eyes (20%) had 0.1-0.3, and 1 eye (6.7%) had 0.05-0.1, and 3 eyes (20.0%) had 0.02-0.05, and 4 eyes (26.7%) had the visual acuity of Light perception-0.02.In the latest diagnosis,1 eye (6.7%) had 0-9mmHg intraocular pressure,14 eyes (93.3%) had 10-21mmHg.15 eyes’retinas were not in place after the operation.Etiology results were:all 38 patients in ARN group were implemented serum TORCH test.18 eyes were fetched vitreous humor samples and underwent vitreous TORCH test respectively while they underwent GCV injection into vitreous cavity and vitrectomy. The serum TORCH detection rate was:37 patients (97.4%) were HSV-IgG, and 36 patients (94.7%) were CMV-IgG, and 34 patients (89.5%) were RV-IgG, Toxo-IgG was 0%. IgM detection rate was 0%. Vitreous humor detection rate was:15 eyes (88.3%) were HSV-IgG, and 5 eyes (11.1%) were CMV-IgG, and 1 eye (35.1%) was RV-IgG., Toxo-IgG was 0%.1 eye (5.6%) was HSV-IgM, and 2 eyes (56.7%) were CMV-IgM. RV-IgM and Toxo-IgM were 0%.21 patients underwent IgG detection, and the result was 10.10±2.38g/l. The detection rate was 100%. Among 18 eyes (18 patients),16 eyes were detected the total IgG in Vitreous humor, and the results were 733.98±830.70mg/dl. The detection rate was 88.9%.2 eyes had not been detected the total IgG.11 eyes had positive GWC results, and 9 eyes were diagnosed as having HSV infection. Patients’ages were 35.11±11.61 years; 2 eyes had been diagnosed as CMV infection, their ages were 53.5±7.78 years. The coincidence rate between Etiological diagnosis and clinical diagnosis was 77.7%. The 15 PVR group patients’serum TORCH detection rate was:14 patients (96.7%) were HSV-IgG, and 15 patients (100%) were CMV-IgG, and 14 patients (93.3%) were RV-IgG. Toxo-IgG was 0%. All IgM detection rate was 0%; 15 eyes’Vitreous humor IgG and IgM detection rate was 0%. The total IgG results of 15 patients were 10.02±2.69g/l, and the detection rate was 100%. The Vitreous humor total IgG of 15 patients was 13.53±17.80mg/dl, and the detection rate was 100.0%Statistical analysis showed that:Using analysis of variance, the Geometric mean titer of blood serum HSV in ARN group is:1:86.30, and the value in PVR group is:1:86.10 (F =0.401, P=0.530). The Geometric mean titer of CMV in ARN group is:1:48.52, and the value in PVR group is:1:30.76, (F= 0.340, P=0.562). The Geometric mean titer of RV in ARN group is:1:72.33 and the value in PVR group is:1:66.53 (F= 0.427, P=0.502). The difference between Two antibodies’Geometric mean titer is not statistically significant. The average of total IgG in 21 ARN patients’blood serum is 10.10±2.38 g/l, and the value in 15 PVR patients is 10.02±2.69g/l. The difference between them is not statistically significant(F=0.428, P=0.517). The average of Vitreous humor total IgG in 16 eyes of ARN patients is 733.98±830.70mg/dl, and the value of 15 PVR patients is 13.53±17. 8mg/dl. The difference between them is statistically significant (F=17.465, P=0.000)The PCR results were:one patient is taken retinal choroidal biopsy to get Tissue samples, and specific DNA of VZV is detected through PCR test, and DNA is negative in HSV test.Conclusion:ARN is an eye syndrome with the main features of acute uveitis, vitreous inflammation, occlusive retina arteritis, retina necrosis and optic neuropathy. Retina detachment is a common complication in the ARN advanced stage. Its diagnosis is primarily based on clinical features. Epidemiological features can provide some basis for the medicine options.Etiological diagnosis of ARN to improve the treatment level is essential. Vitreous humor antibodies to the virus detection are indirect evidences for diagnosis of infections pathogens. Through choroid retina to get infected tissue biopsy samples, and through PCR test, the virus DNA can be directly detected and etiological diagnosis can be confirmed.The primary treatment for ARN patients is systemic anti-virus and preventive laser treatment. For youth group (≤36 years), ACV treatment is the first choice. For older group (≥50 years), GCV treatment is the first choice, and try to improve prognosis. For 36-50 year age people, give ACV treatment at first. If the illness deteriorated after 10 days, GCV would be implemented. For the patient who has systemic deterioration, but has not yet appeared retina detachment, GCV Vitreous cavity injection should be given as soon as possible. The effect is perfect. For the patient who has retina detachment secondary rhegmatogenous or PVR, vitrectomy and eye laser photocoagulation combined silicone oil tamponade should used as soon as possible to save the patient’s vision.
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