In Reply Spaide questions why we selected the case report of PORN by Greven et al1 as a key reference when the association with varicella-zoster virus infection was established by polymerase chain reaction and not by light or electron microscopic localization of viral inclusions or capsids. First, we believe the ophthalmoscopic findings and clinical course of the disorder were consistent with the clinical condition referred to as PORN. Second, the polymerase chain reaction procedure described by Greven and colleagues included safeguards that minimized false-positive results. Third, their Figure 4A demonstrates at least 2 retinal cells that contain intranuclear inclusions, consistent with viral retinitis. The particular reason we cited this study, though, is because it included a histopathologic photograph of partial retinal necrosis. Besides our case, we are not aware of another example that depicts early involvement in PORN. In their Figure 4B, Greven and colleagues show partial retinal necrosis with relative preservation of the outer retina. Although the authors do not mention the incongruity of this finding with the acronym, their illustration raises the same remarkable question that Lorenz E. Zimmerman, MD, asked: if necrosis of the inner retina precedes that of the outer retina, why does deep retina appear involved first on ophthalmoscopic examination?
Margo CE, Friedman SM. Vintage Progressive Outer Retinal Necrosis—Reply. JAMA Ophthalmol. 2015;133(2):231. doi:10.1001/jamaophthalmol.2014.4512
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