Bilateral Retrobulbar Neuritis Due to Varicella Zoster Preceding Retinal Necrosis in a Patient with AIDS

Objective: The purpose of this study is to describe a case report of varicella zoster (VZV) infection presenting as bilateral retrobulbar neuritis affecting optic tracts, chiasm, and bilateral optic nerves preceding bilateral progressive outer retinal necrosis in a single patient with AIDS. Methods: The clinical course of a single patient with confirmed VZV infection will be described including presentation, diagnosis, and treatment. Results: The affected patient presented with acute, bilateral vision loss, and headache. The patient's history was devoid of past, concurrent, or subsequent development of herpes zoster dermatitis. The patient lacked signs of meningeal irritation or infection. Diagnosis of VZV arachnoiditis and retrobulbar optic neuritis were confirmed by radiological and CSF examination and preceded the clinical identification of retinal involvement. Despite early, aggressive treatment with intravenous antiviral and steroids, as well as intravitreal antiviral therapy, complete bilateral visual loss resulted. Conclusion: Varicella zoster continues to present uniquely in patients with acquired immune deficiency syndrome. Absence of retinal involvement doesn't rule out retrobulbar visual pathways involvement by VZV. The astute clinician should be aware of this presentation and suspect the involvement of varicella zoster in immunocompromised patients presenting with retrobulbar optic neuritis and meningeal involvement with normal fundus exam.