A Case of Cytomegalovirus Retinitis Following Intravitreal Dexamethasone Implant in an Immunocompetent Patient with Uveitis

PURPOSE: We report a case of cytomegalovirus (CMV) retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient diagnosed with non-infectious uveitis. CASE SUMMARY: A 60-year-old woman was referred to our hospital for recurrent anterior uveitis. Fundus examination and fluorescein angiography showed dense vitritis, but no definite retinal infiltration. After laboratory examinations, the patient was diagnosed with non-infectious panuveitis. Uveitis was much improved after the patient started taking oral steroid medication. However, the patient complained of systemic side effects from the oral steroids. Medication was stopped, and an intravitreal dexamethasone implant was fitted to address worsening inflammation. Two months later, perivascular retinal infiltration developed and vitritis recurred. Viral retinitis was suspected, and the patient underwent diagnostic vitrectomy adjunctive with intravitreal ganciclovir injection. Polymerase chain reaction of vitreous fluid confirmed the diagnosis of CMV retinitis. The patient has remained inflammation-free for more than 20 months after vitrectomy, single ganciclovir injection, and 2 months of oral valganciclovir medication. CONCLUSIONS: This is a case report of CMV retinitis following placement of an intravitreal dexamethasone implant in an immunocompetent patient without any risk factors or previous history of immunosuppression. Potential risk factors for CMV retinitis should be evaluated and careful follow-up should be performed when intravitreal dexamethasone injections are unavoidable for the treatment of non-infectious uveitis.

Retinite por citomegalovírus em paciente com Síndrome de Good / Cytomegalovirus retinitis in Good Syndrome

Resumo A Síndrome de Good é uma síndrome paraneoplásica caracterizada pela associação de timoma e hipogamaglobulinemia, cursando com imunossupressão. Relatamos um caso raro de retinite por citomegalovírus em paciente com esta síndrome.

Abstract Good syndrome is a paraneoplastic syndrome characterized by the association of thymoma and hypogammaglobulinemia, with immunosuppression. We report a rare case of cytomegalovirus retinitis in a patient with this syndrome.

Ocular Ischemic Syndrome as the Initial Presenting Feature of Cytomegalovirus Retinitis

No abstract available.

Manifestaciones oculares de enfermedad Sistémica: Retinitis por CMV en pacientes no HIV / Ocular Manifestations of Systemic Disease: CMV Retinitis in Non-HIV Patients

La retinitis es la manifestación más común de la infección por CMV en inmunocomprometidos. Es una infección oportunista representando el 90% de las retinitis infecciosas, y la principal causa de ceguera en este grupo de pacientes. La retinitis por Citomegalovirus (CMV) puede desarrollarse en pacientes no HIV con deterioro de la inmunidad secundario a medicación inmunodepresora o enfermedades malignas que originen por ser estados de inmunodepresión. Se presentan dos estudios de casos. A continuación una síntesis de la evidencia que incluye información del diagnóstico, tratamiento tanto con Ganciclovir, como con Foscarnet.

Retinitis is the most common manifestation of CMV infection in immunocompromised patients. It is an opportunistic infection that accounts for 90% of infectious retinitis andthe main cause of blindness in this group of patients. Cytomegalovirus (CMV) retinitis can develop in non-HIV patients with impaired immunity due to immunosuppressive medication or malignant disease resulting from the status of immunosuppression. Two case studies are presented. Below, there is a synthesis of the evidence, including information on the diagnosis and treatment with both Ganciclovir and Foscarnet.

Comportamiento de las enfermedades oftalmológicas en pacientes con VIH-SIDA / Behavior of eye diseases in HIV-Aids patients

Objetivo: caracterizar las enfermedades oftalmológicas en pacientes con VIH-SIDA diagnosticadas en el Servicio de Uveítis e Inflamaciones Oculares del Instituto Cubano de Oftalmología Ramón Pando Ferrer. Métodos: se realizó un estudio descriptivo longitudinal retrospectivo en 39 ojos (24 pacientes) quienes cumplieron los criterios de inclusión y exclusión de la investigación. Las variables estudiadas fueron: edad, sexo, enfermedades oftalmológicas asociadas, lateralidad, agudeza visual y conteo de linfocitos TCD4+ al inicio y al final de la enfermedad oftalmológica, las complicaciones asociadas y la pérdida de la agudeza visual. Resultados: predominó el sexo masculino (83,3 por ciento) y el grupo etario entre 31 y 45 años, que representó el 45,8 por ciento de la muestra. Existió un gran deterioro visual desde el inicio de la enfermedad, sin mejorias significativas una vez estabilizada esta (p= 0,503). Las enfermedades oftalmológicas más frecuentes en orden de frecuencia fueron la sífilis ocular (32,1 por ciento), la retinitis por citomegalovirus (28,6 por ciento) y la toxoplasmosis (17,8 por ciento). El desprendimiento de retina (27,2 por ciento), las membranas epirretinales (22,7 por ciento) y las cataratas (18,2 por ciento) fueron las complicaciones más frecuentes. Conclusiones: la sífilis ocular es la enfermedad más frecuente en pacientes con VIH-SIDA y no guarda relación con el conteo CD4+. La retinitis por citomegalovirus se asocia a conteos de CD4+ bajos y provoca mayor cantidad de complicaciones. Más de la mitad de los ojos con enfermedades oftalmológicas en los pacientes con VIH- SIDA evolucionan a la ceguera(AU)

Objective: to characterize the eye diseases observed in HIV-AIDS patients diagnosed at the Uveitis and Eye Inflammation Service at "Ramon Pando Ferrer" Cuban Institute of Ophthalmology. Methods: retrospective, longitudinal and descriptive study of 39 eyes (24 patients, who met the inclusion and exclusion criteria of the research. The study variables were age, sex, associated eye diseases, laterality, visual acuity and TCD4+ lymphocyte count at the beginning and the end of the eye disease, the related complications and the loss of visual acuity. Results: males (83.3 percent) and the 31-45 y age group (45.8 percent) of the sample predominated. There was great visual deterioration since the onset of disease, without any significant improvement once the patient is stabilized (p= 0.503). The most common eye diseases were ocular syphilis (32.1 percent), cytomegalovirus retinitis (28.6 percent) and toxoplasmoxis (17.8 percent). Retinal detachment (27.2 percent), epiretinal membranes (22.7 percent) and cataract (18.2 percent) were the most frequent complications. Conclusions: Ocular syphilis is the most common disease in HIV-AIDS patients and is unrelated to CD4+ count. Cytomegalovirus retinitis is associated to low CD4+ counts and unleash higher number of complications. Over half of the eyes with diseases in HIV-AIDS patients evolved into blindness(AU)

Retinitis por citomegalovirus en un paciente con VIH / Cytomegalovirus retinitis in a HIV patient

La retinitis por citomegalovirus es la infección ocular más frecuente en pacientes con un recuento de linfocitos CD4 inferior a 200 por µL. El aspecto oftalmoscópico de las lesiones se caracteriza, en la mayoría de los casos, por infiltrados retinianos resultados de la necrosis retiniana producida por citomegalovirus y el edema en asociación con hemorragias. Estas lesiones se disponen, por lo general, siguiendo las arcadas vasculares temporales con invasión hacia la mácula. Se presentó una paciente de 24 años de edad, femenina, blanca, ama de casa, con antecedentes patológicos personales oculares sin datos de interés, y antecedentes patológicos personales generales de ser diagnosticadas con VIH. Hace cuatro años que comenzó con tratamiento antirretroviral, y tuvo cambios de tratamiento en dos ocasiones. El último fue impuesto en mayo del año 2011, con el cual presentó mala adherencia terapéutica, y comenzó desde entonces a presentar disminución de su peso corporal de forma marcada en breve período de tiempo. Refiere que desde hace unos meses comenzó a presentar una disminución progresiva de la agudeza visual en el ojo derecho, acompañado de visión borrosa. Adquiere gran importancia este caso, ya que ante la supervivencia de los pacientes con sida, va a ser cada vez más frecuente la aparición de las afecciones oculares relacionadas con esta enfermedad. Dentro de ellas se encuentran las infecciones oportunistas mayores como la retinitis por citomegalovirus(AU)

Retinitis caused by cytomegalovirus is the most frequent opportunistic infection in patients with a lymphocyte count CD4 less 200 µL. The ophthalmological aspect of the lesions in most of cases is characterized by retinal infiltrates derived from the retinal necrosis caused by cytomegalovirus and the edema associated to hemorrhages. In general, these lesions are arranged in the same form as the temporal vascular arcades and go into the macula. Here is a 24 years-old Caucasian female patient , housewife with a history of ocular problems with no interesting data and positive diagnosis of HIV, She began an antiretroviral treatment four your ago, which was changed twice. The last one was administered on May 2011 and the therapeutic adherence was inadequate. Since then, she began losing weight significantly in a short period of time. Some months ago, she reported a progressive reduction of the visual acuity in the right eye and blurred vision. This case is very important because, due to the survival rate of AIDS patients, the occurrence of ocular diseases related to it will become more frequent. One of them is major opportunistic infection such as cytomegalovirus retinitis(AU)

Cutaneous cytomegalovirus infection presenting as persistent plaque on the nose in an HIV-AIDS patient

Cytomegalovirus (CMV) rarely manifests as cutaneous lesions in immunocompromised patients. Only 25 cases have been reported since 1991. It causes latent infection among exposed individuals but reactivation may occur in immunocompromised patients causing encephalitis, pneumonitis, colitis, retinitis and congenital fetal infection. Cutaneous manifestations of CMV infection usually present with various skin lesions such as ulcers, erosions, erythematous morbilliform rash, vesicles and bullae. We report a case of cutaneous CMV infection in an HIV-AIDS patient presenting as a persistent ulcerated plaque on the nose. The lesion slowly evolved into a plaque which partially destroyed the right alar rim. Skin punch biopsy showed perivascular giant cells with large eosinophilic inclusions resembling an owl's eye consistent with CMV infection. He was subsequently diagnosed with CMV retinitis because of blurring of vision and findings of retinal necrosis on fundoscopy. Oral valganciclovir 1800mg/day was given for 21 days. Significant thinning and drying of the plaque with no further progression of ulceration of the alar rim were noted.

When Dermatomyositis Patient Has Blurring of Vision – What Goes Wrong?

Cytomegalovirus (CMV) retinitis occurs predominantly in Human Immunodeficiency Virus (HIV) -infected patients. It was also reported in HIV-seronegative patients with systemic autoimmune disorder requiring systemic immunosuppression, organ or bone marrow transplantation, haematological or breast malignancy receiving chemotherapy, ocular diseases following intraocular or periocular corticosteroid injection, diabetes mellitus and Good syndrome. However, CMV retinitis in patients with concurrent dermatomyositis and malignancy has not been previously reported. It has not been reported in cancer other than haematological or breast malignancy, or in cancer patient prior to chemotherapy. We report a case of 40-year-old HIV-seronegative woman with underlying dermatomyositis and lung malignancy who developed right CMV retinitis which relapsed after recommencement of immunosuppressant. Both episodes of CMV retinitis were successfully treated after taken her immunocompromised state into consideration.

Ocular Inflammation Associated with Systemic Infection / 한양의대학술지

Systemic infections that are caused by various types of pathogenic organisms can be spread to the eyes as well as to other solid organs. Bacteria, parasites, and viruses can invade the eyes via the bloodstream. Despite advances in the diagnosis and treatment of systemic infections, many patients still suffer from endogenous ocular infections; this is particularly due to an increase in the number of immunosuppressed patients such as those with human immunodeficiency virus infection, those who have had organ transplantations, and those being administered systemic chemotherapeutic and immunomodulating agents, which may increase the chance of ocular involvement. In this review, we clinically evaluated posterior segment manifestations in the eye caused by hematogenous penetration of systemic infections. We focused on the conditions that ophthalmologists encounter most often and that require cooperation with other medical specialists. Posterior segment manifestations and clinical characteristics of cytomegalovirus retinitis, endogenous endophthalmitis, toxoplasmosis, toxocariasis, and ocular syphilis are included in this brief review.

Safety and Efficacy of Intravitreal Ganciclovir Injections More than 10 Times for Cytomegalovirus Retinitis

PURPOSE: To study the treatment outcomes in patients who were administered multiple intravitreal ganciclovir injections more than 10 times alone without systemic anti-cytomegalovirus therapy for cytomegalovirus retinitis. CASE SUMMARY: A 64-year-old man who underwent immunosuppressive therapy after thymectomy due to an invasive thymoma and pure red-cell aplasia, a 60-year-old woman who underwent chemotherapy after diagnosis of diffuse large B-cell lymphoma, a 49-year-old man with a history of bone marrow transplantation due to acute myeloid leukemia, a 29-year-old woman with dermatomyositis treated with oral steroids and cyclosporine, and a 47-year-old woman who received intravitreal dexamethasone implant injections, intravitreal and subtenon steroid injections due to Behcet's disease were diagnosed with cytomegalovirus retinitis. All patients showed systemic complications such as pancytopenia after systemic anti-cytomegalovirus therapy, and therefore, they were administered multiple intravitreal ganciclovir injections alone. Best-corrected visual acuities improved in all patients, except in one case, where viral lesions were observed in the fovea. Retinal hemorrhaging and infiltrative lesions decreased in all patients. No severe complication was observed during the injection and in the follow-up period. CONCLUSIONS: Multiple intravitreal ganciclovir injections alone can be used as a treatment modality for cytomegalovirus retinitis to avoid the systemic side effects of systemic anti-cytomegalovirus therapy.

Sensitivity of the Cytomegalovirus Antigenemia Assay to Diagnose Cytomegalovirus Retinitis / 감염과화학요법

BACKGROUND: Cytomegalovirus (CMV) retinitis is one of the most important tissue-invasive CMV diseases in immunocompromised patients. Since 1980, non-invasive diagnostic methods, notably the CMV antigenemia assay, have been widely used as adjunct tests to diagnose tissue-invasive CMV diseases. However, there are limited data on the diagnostic value of the CMV antigenemia assay for diagnosing CMV retinitis. MATERIALS AND METHODS: We performed a retrospective review of all cases of CMV retinitis at Asan Medical Center, Seoul, South Korea over a 9-year period. The diagnosis of CMV retinitis was made by experienced ophthalmologists according to medical history and an ophthalmoscopic appearance of typical retinopathy, together with absence of an alternative diagnosis. RESULTS: We analyzed 44 patients with CMV retinitis (affecting 57 eyes) for whom the CMV antigenemia assay was performed. Of the 44 patients, 31 (70%) were HIV-uninfected and 13 (30%) were HIV-infected. The overall sensitivity of the CMV antigenemia assay was 66% (95% confidence interval [CI] 50–80%). The test’s sensitivity showed a non-significant trend towards being higher in HIV-infected patients than in HIV-uninfected patients (sensitivity 85% vs 58%, respectively, P = 0.16). In a subgroup analysis of the 35 patients without other concurrent tissue-invasive CMV disease, the sensitivity of the CMV antigenemia assay was 57% (95% CI 40–74%). CONCLUSIONS: The CMV antigenemia assay has limited value as a non-invasive diagnostic adjunct test for CMV retinitis. Therefore, the results of the assay need to be interpreted in the context of underlying disease, clinical presentation, and ophthalmoscopic findings.

Late emergence of A594V and L595W mutations related to ganciclovir resistance in a patient with HCMV retinitis and long-term HIV progression

The emergence of ganciclovir (GCV) resistance during the treatment of human cytomegalovirus (HCMV) infection is a serious clinical challenge, and is associated with high morbidity and mortality. In this case report, we describe the emergence of two consecutive mutations (A594V and L595W) related to GCV resistance in a patient with HCMV retinitis and long-term HIV progression after approximately 240 days of GCV use. Following the diagnosis of retinitis, the introduction of GCV did not result in viral load reduction. The detected mutations appeared late in the treatment, and we propose that other factors (high initial HCMV load, previous GCV exposure, low CD4+ cell count), in addition to the presence of resistance mutations, may have contributed to the treatment failure of HCMV infection in this patient.

Human leucocyte antigen profile in patients with aids and cytomegalovirus retinitis with and without macular involvement

Cytomegalovirus retinitis is one of the ocular manifestations of AIDS. The objective of the present study was to determine possible associations of class I and II HLA antigens and alleles in patients with AIDS and cytomegalovirus retinitis (CMV-R) with and without macular involvement. Method: The study population consisted of 22 patients with AIDS and CMV-R with macular involvement (Group I), 19 patients with AIDS and CMV-R without macular involvement (Group II), and 202 individuals with negative serology for human immunodeficiency virus (Group III - control). Class I HLA antigens were typed by classical serology. Class II alleles were identified using sequence-specific oligonucleotide primers hybridized with amplified DNA. Results: HLA-DRB1*14 and HLA-DRB1*10 specificities were more frequent among patients with macular involvement, possibly indicating greater susceptibility to this condition. In contrast, the HLA-B35 antigen may be associated with protection against macular involvement since it was significantly more frequent among patients without this involvement. Conclusions: The HLA-DRB1*14 and HLA-DRB1*10 alleles may favor the development of CMV-R with macular involvement, whereas the HLA-B35 subtype may be associated with protection against macular involvement...

Citomegalovirus: de la primoinfección a la retinitis / Cytomegalovirus: from primoinfection to retinitis

Una vez sucedida la primoinfección, el citomegalovirus se establece latente en las células mieloides progenitoras, y la reactivación viral intermitente procedente de macrófagos activados o células dendríticas es controlada por una fuerte respuesta viral específica de células CD4 y CD8. La retinitis por citomegalovirus está caracterizada por una necrosis retinal como consecuencia de efectos citopáticos virales que ocurre en pacientes en quienes la función de células T está comprometida, como resultado de trasplantes de órganos, SIDA o tratamiento inmunosupresor. El diagnóstico de retinitis por citomegalovirus puede ser confirmado por amplificación del ADN viral en muestras de humor acuoso. El tratamiento de la retinitis por citomegalovirus se basa en la actualidad en la reconstitución del sistema inmune con la terapia TARGA y combinado a una terapia anticitomegalovirus (ganciclovir, foscarnet, cidofovir y valganciclovir). El citomegalovirus está también implicado en dos formas de enfermedad del segmento anterior en adultos inmunocompetentes llamado uveítis anterior por citomegalovirus y queratitis endotelial por citomegalovirus.

Once first infection occurs, cytomegalovirus (CMV) remains latent in myeloid progenitor cells and the intermittent viral relapsing proceeding from activated macrophages and dendritic cells, is controlled by strong specific viral response CD4cell y CD8-cell. CMV retinitis is characterized by spreading retinal necrosis due to viral cytopathic effect occurs in patients who have impaired T-cell function as a result of transplantation, AIDS, or immuno-suppressive treatment. The diagnosis of CMV retinitis can be confirmed by PCR amplification of viral DNA in aqueous. Updated treatment for CMV retinitis is based on the immune system recovery with highly activity anti-retroviral therapy combined with anti CMV therapy (ganciclovir, foscarnet, cidofovir and valganciclovir). CMV is also implicated in two forms of anterior segment disease in immuno-competent adults, namely CMV anterior uveitis and CMV corneal endotheliitis.

Retinitis por citomegalovirus en pacientes infectados con el Virus de la Inmunodeficiencia Humana con tratamiento TARGA / Cytomegalovirus retinitis in patients infected with Human Immunodeficiency Virus with Antiretroviral Therapy, Highly Active

OBJETIVOS: Determinar las características clínicas de los pacientes infectados con el virus de la inmunodeficiencia humana que presentan retinitis por Citomegalovirus en tratamiento TARGA del Hospital Nacional Luis N. Sáenz. MATERIALES y METODOS: Estudio descriptivo, observacional, transversal, retrospectivo. Se incluyeron a 31 pacientes con VIH+ diagnosticados con retinitis por CMV en el Hospital nacional LNS-PNP durante el periodo de estudio 2009-2011. La recolección de los datos incluyó las características sociodemográficas, historia clínica y oftalmológica. RESULTADOS: Las características sociodemográficas frecuentes fueron ser mayores de 30 años (67.7 por ciento), varones (83.9 por ciento) y tener un tiempo de enfermedad mayor de 24 meses (61.3 por ciento). Las infecciones oportunistas fue la característica más frecuente (93.5 por ciento), siendo la tuberculosis (67.7 por ciento) y candidiasis (45.2 por ciento) los agentes de mayor proporción. El contacto sexual múltiple fue el comportamiento sexual de mayor proporción (80.6 por ciento). Los flotantes y los flashes fueron los síntomas más frecuentes (19.4 por ciento) junto con una rápida y progresiva disminución de la agudeza visual menor de 20/50 (87 por ciento); al igual que un recuento de linfocitos T CD 4 menor de 40 cl/ul (58.1 por ciento). CONCLUSION: Las principales características fueron pacientes mayores de 30 años, varones y con un tiempo de enfermedad mayor de 24 meses, con Infecciones oportunistas y el antecedente de CMV previo, contacto sexual múltiple. Síntomas clínicos frecuentes fueron flotantes y los flashes, y pobre agudeza visual y recuento de linfocitos T CD 4 menor de 40 cl/ul.

OBJECTIVES: To determine the clinical characteristics of patients infected with human immunodeficiency virus with Cytomegalovirus retinitis in the National Hospital Luis N. Saenz. MATERIALS AND METHODS: A descriptive, observational, cross-sectional, retrospective. We included 34 HIV+ patients diagnosed with CMV retinitis in the National Hospital LNS-PNP during the study period from 2009 to 2012. The data collection included demographic characteristics, medical history and vision. RESULTS: The characteristics common sociodemografics were being older than 30 years (67.7 per cent), males (83.9 per cent) and have a sick time of 24 months (61.3 per cent). Opportunistic infections were the most frequent feature (93.5 per cent), and tuberculosis (67.7 per cent) and candidiasis (45.2 per cent) higher proportion agents. Multiple sexual contacts were sexual behavior largest proportion (80.6 per cent). Floaters and flashes were the most common symptoms (19.4 per cent) together with rapid and progressive decrease of visual acuity less than 20/50 (87 per cent), as well as a T-cell count below 40 CD 4 cl/ul (58.1 per cent). CONCLUSSION: The main features were patients age 30, male, with a time of illness over 12 months with Infections opportunistic and a history of prior CMV, multiple sexual contact. Clinical symptoms were floating frequently and flashes, and poor visual acuity and T lymphocyte count CD 4 below 40 cl/ul.

Two Cases of Intravitreal Ganciclovir Injection for Cytomegalovirus Retinitis

PURPOSE: To report 2 cases of cytomegalovirus retinitis treated with intravitreal ganciclovir. CASE SUMMARY: A 29-year-old female (Case 1) who received immunosuppressive therapy with tacrolimus and mycophenolate mofetil for 3 months after pancreatic transplantation, was given an intravitreal Bevacizumab injection 4 times in each eye under the suspicion of bilateral central retinal vein occlusion. During follow-up, a new lesion with white opacification and multiple snowballs appeared in the left eye. Suspecting cytomegalovirus retinitis, we administered an intravitreal ganciclovir injection resulting in a decrease of white opacification and improvement of visual acuity. A 66-year-old male (Case 2) who was receiving treatment for general weakness and heart failure, presented with visual disturbance in both eyes. Fundoscopic examination revealed white opacification, multiple snowballs and retinal hemorrhage in the left eye; diagnostic vitrectomy was performed. Macular edema and subretinal fluid continued after the vitrectomy and the serologic testing revealed an IgG titer positive for cytomegalovirus, therefore, an intravitreal injection of ganciclovir was given. Macular edema and subretinal fluid decreased and visual acuity improved. CONCLUSIONS: Intravitreal ganciclovir can be an effective treatment option for the management of CMV retinitis.

Cytomegalovirus Retinitis after Intravitreal Bevacizumab Injection in an Immunocompetent Patient

We report a case of cytomegalovirus (CMV) retinitis after intravitreal bevacizumab injection. A 61-year-old woman with diabetic macular edema developed dense vitritis and necrotizing retinitis 3 weeks after intravitreal bevacizumab injection. A diagnostic vitrectomy was performed. The undiluted vitreous sample acquired by vitrectomy was analyzed by polymerase chain reaction and culture. Polymerase chain reaction of the vitreous was positive for CMV DNA. Other laboratory results did not show evidence of other infectious retinitis and systemic immune dysfunction. Human immunodeficiency virus antibodies were also negative. After systemic administration of ganciclovir, retinitis has resolved and there has been no recurrence of retinitis during the follow-up period of 12 months. Ophthalmologists should be aware of potential risk for CMV retinitis after intravitreal bevacizumab injection.

Spontaneous Resolution of Intravitreal Steroid-Induced Bilateral Cytomegalovirus Retinitis

A 73-year-old woman underwent vitrectomy and intravitreal triamcinolone acetonide (IVTA) of the right eye and cataract surgery with IVTA of the left eye, for bilateral diabetic macular edema. The patient presented with visual loss in both eyes three-months postoperatively. The fundoscopic examination revealed white-yellow, necrotic peripheral lesions in the superotemporal quadrant of both eyes. Although bilateral acute retinal necrosis was suspected, azotemia resulting from diabetic nephropathy limited the use of acyclovir. Antiviral treatment was not started. A sample of the aqueous humor for polymerase chain reaction (PCR) analysis was obtained. One week later, the PCR results indicated the presence of cytomegalovirus (CMV). Since the retinal lesions did not progress and did not threaten the macula, the patient was followed without treatment for CMV. The retinal lesions progressively regressed and completely resolved in both eyes by six months of follow-up. Patients with IVTA-induced CMV retinitis may not require systemic treatment with ganciclovir.

Ocular Manifestations of Acquired Immunodeficiency Syndrome in Korea

The clinical features of HIV/AIDS-related ocular manifestations in Korean patients were investigated in this study. Data on 200 consecutive Korean patients diagnosed with AIDS who visited the Seoul National University Hospital from January 2003 to June 2008 were reviewed. Fifty-seven patients (28.5%) had ocular manifestations, and they showed significantly lower CD4+ T cell count than patients without ocular manifestations. Among them, 23 (40.3%) patients showed retinal microvasculopathy, and 22 (38.5%) patients showed cytomegalovirus (CMV) retinitis. Other manifestations included retinal vein occlusion (n = 4), herpes zoster ophthalmicus (n = 4), syphilitic uveitis (n = 2), acute retinal necrosis (n = 1), and progressive outer retinal necrosis (n = 1). The mean CD4+ lymphocyte counts of the patients with retinal microvasculopathy and cytomegalovirus retinitis were 108.5 cells/microL and 69.4 cells/microL, respectively. In conclusion, ocular manifestations including CMV retinitis are common complications in Korean patients with AIDS even in the era of highly active anti-retroviral therapy. Compared to previous reports in western countries, prevalence of CMV retinitis is relatively low and CD4+ lymphocytes count at the time of diagnosis is relatively high.

Cytomegalovirus retinitis associated with acquired immunodeficiency syndrome / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cytomegalovirus (CMV) retinitis is the most severe intraocular complication that results in total retinal destruction and loss of visual acuity in patients with acquired immunodeficiency syndrome (AIDS). This study aimed to investigate the fundus characteristics, systemic manifestations and therapeutic outcomes of CMV retinitis associated with AIDS.</p><p><b>METHODS</b>It was a retrospective case series. CMV retinitis was present in 39 eyes (25 patients). Best corrected visual acuities, anterior segment, fundus features, fundus fluorescence angiography (FFA) and CD4(+) T-lymphocyte counts of the patients with CMV retinitis associated with AIDS were analyzed. Intravitreal injections of ganciclovir (400 µg) were performed in 4 eyes (2 patients).</p><p><b>RESULTS</b>Retinal vasculitis, dense, full-thickness, yellow-white lesions along vascular distribution with irregular granules at the border, and hemorrhage on the retinal surface were present in 28 eyes. The vitreous was clear or mildly opaque. Late stage of the retinopathy was demonstrated in 8 eyes characterized as atrophic retina, sclerotic and attenuated vessels, retinal pigment epithelium (RPE) atrophy, and optic nerve atrophy. Retinal detachment was found in 3 eyes. The average CD4(+) T-lymphocyte count in peripheral blood of the patients with CMV retinitis was (30.6 ± 25.3) × 10(6)/L (range, (0 - 85) × 10(6)/L). After intravitreal injections of ganciclovir, visual acuity was improved and fundus lesions regressed.</p><p><b>CONCLUSIONS</b>CMV retinitis is the most severe and the most common intraocular complication in patients with AIDS. For the patients with yellow-white retinal lesions, hemorrhage and retinal vasculitis without clear cause, human immunodeficiency virus (HIV) serology should be performed. Routine eye examination is also indicated in HIV positive patients.</p>