Prophylactic argon laser coagulation for rhegmatogenous retinal detachment in AIDS patients with cytomegalovirus retinitis.

BACKGROUND: The incidence of cytomegalovirus (CMV) retinitis in patients with acquired immunodeficiency syndrome (AIDS) reaches 20-45%. Despite aggressive medical treatment, rhegmatogenous retinal detachments develop in up to 30% of the affected eyes. Surgical repair is often difficult due to multiple large and hardly visible retinal holes with vitreal traction. Pars plana vitrectomy with instillation of silicone oil is the procedure of choice, giving limited functional results with anatomical reattachment. METHODS: We performed prophylactic laser coagulation in AIDS patients with medically treated CMV retinitis to prevent a progressive retinal detachment. Twenty-two quiescent CMV lesions in 22 eyes of 20 patients were treated with argon green laser coagulation. Each CMV lesion was completely surrounded with a double or triple row of laser spots (500-600 mumols; 0.2 s; gray-white lesions). RESULTS: The duration of follow-up was 2-24 months. Histopathologic evaluation was possible in two eyes of one patient. Reactivated or smoldering CMV retinitis crossed the laser scars in 11 eyes, making additional laser coagulation necessary. In four eyes retinal holes in the CMV scar tissue led to retinal detachment, which stopped at the laser scar. In three eyes the detachment is still controlled by the laser scar. In one eye, the detachment stopped at the laser scar for 6.5 months and then slowly progressed across it. There were no complications associated with our laser treatment. CONCLUSION: Prophylactic argon laser coagulation in quiescent CMV retinitis seems to reduce the rate of progressive retinal detachment with no need for vitrectomy and silicone oil tamponade.

Endothelial precipitates and laser flare photometry in patients with acquired immunodeficiency syndrome: a screening test for cytomegalovirus retinitis?

Patients with acquired immunodeficiency syndrome (AIDS) who present with cytomegalovirus (CMV) retinitis show pathognomonic endothelial precipitates suggestive of primary anterior uveitis or secondary changes due to a spill-over from the posterior chamber. Laser flare photometry allows quantification of the intensity of anterior affection. We wanted to establish anterior-chamber flare values in AIDS patients with and without CMV retinitis and to find out whether CMV retinitis is preceded by an elevation of the flare value. In all, 25 men with AIDS who presented with CMV retinitis and 27 who did not have CMV retinitis but showed a CD4 count of < or = 200 cells/microliter blood were enrolled in a prospective study. Slit-lamp examination was performed, followed by indirect ophthalmoscopy and laser flare photometry after dilation of the pupil with tropicamide eye drops. Patients with CMV retinitis were followed every 10 days and the others, every 4 weeks. A group of 51 human immunodeficiency virus (HIV)-negative men served as a control group. AIDS patients with CMV retinitis showed a significantly higher flare count in the affected eye (12.4 photons/ms; n = 26) as compared with the unaffected partner eye (4.2 photons/ms; P < or = 0.0001; n = 18) and with eyes of AIDS patients without CMV retinitis (4.1 photons/ms; P < or = 0.0001; n = 50). The count in the latter eyes was also significantly higher than the control value (3.1 photons/ms; P < or = 0.0001; n = 102). Typical reticulate endothelial precipitates were found in 92% of AIDS patients with CMV retinitis. During the study, five eyes of three patients developed a fresh CMV retinitis, but a preceding rise in the flare count was not observed. Laser flare photometry follows the occurrence of pathognomonic reticulate endothelial precipitates. It lags behind the development and the extension of CMV retinitis. Therefore, it cannot be used as a screening test for early detection of CMV retinitis.

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an immunocompetent patient]. / Behandlung der Toxoplasmose-Retinochoroiditis mit Atovaquon bei immunkompetenten Patienten.

BACKGROUND: In Central Europe ocular toxoplasmosis is the leading cause of posterior uveitis. It is a major cause of severe visual loss and blindness in young people. Drugs for treatment of active lesions (tachyzoites) have been available for decades but are seen controversial especially because of sometimes serious side effects. These drugs don't seem to shorten the active inflammation nor the recurrence rate, in particular because of the poor effect on the cystic form (bradyzoites). Atovaquone (hydroxynaphthoquinone) is well tolerated systemically and is effective against tachyzoites and bradyzoites of Toxoplasma gondii so that we hope to reduce the recurrence rate. PATIENT HISTORY AND CLINICAL FINDINGS: Two immunocompetent patients with the first and respective second symptomatic recurrence of unilateral active toxoplasmic retinochorioiditis located within the major temporal vascular arcades were treated with Atovaquone and Fluorocortolone because of an impending loss of central visual function. THERAPY AND CLINICAL COURSE: Under the treatment with Atovaquone (3 x 750 mg/day) for three weeks and tapering of the Fluorocortolone the active lesions healed quickly. After a few weeks, atrophic and remarkably little pigmented scars remained. No side effects were observed. After a period of 7 and respective 11 months no recurrence occurred. CONCLUSIONS: Atovaquone is an effective and well tolerated drug for the treatment of active ocular toxoplasmosis in immunocompetent patients. Its efficacy against tachyzoites and cysts of Toxoplasma gondii relative to other drugs remains to be determined by further clinical trials.

Rifabutin-associated anterior uveitis in patients infected with human immunodeficiency virus.

Iridocyclitis, arthralgia, and pseudojaundice have been identified as dose-dependent adverse effects in patients with acquired immunodeficiency syndrome (AIDS) who are treated orally with rifabutin for Mycobacterium avium intracellulare complex (MAC) infections. Nine episodes of acute anterior uveitis of varying severity ranging from mild iridocyclitis to anterior uveitis with fibrin or hypopyon, mimicking endogenous metastatic endophthalmitis, occurred in seven patients. At the time of presentation, all seven patients were receiving rifabutin at a dose ranging from 300 to 600 mg daily. Iridocyclitis was bilateral in four of seven patients, in two cases simultaneously and in two cases successively. Inflammation resolved rapidly on treatment with systemic and topical antibiotics, on corticosteroid therapy, and on discontinuation of rifabutin. In two cases of mild iridocyclitis, cessation of rifabutin alone led to resolution of the uveitis. The combination of rifabutin, clarithromycin, and fluconazole may increase the risk for anterior uveitis in patients with AIDS. All of our patients were treated with fluconazole, with clarithromycin, or with a combination of both substances in addition to rifabutin. Identification of rifabutin-induced uveitis is important because hypopyon uveitis in the immunocompromised patient generally evokes intensive and, sometimes, invasive ophthalmic and systemic workup and therapy. We suggest it to be sufficient for resolution of the inflammatory signs to discontinue rifabutin medication.

Anterior uveitis associated with rifabutin medication in AIDS patients.

Eight episodes of rifabutin-associated anterior uveitis in AIDS patients are reported. Uveitis developed after two weeks to nine months of medication, commonly when rifabutin was administered along with clarithromycin and/or fluconazole. Recovery was closely correlated to suspending rifabutin early, while less dependent on total rifabutin dose or epidemiological patient characteristics. In two cases, discontinuation of rifabutin alone relieved ocular inflammation. Repeated exposure to rifabutin was successful with a reduced dosage in three patients.

[AIDS: infections of the retina and choroid]. / AIDS: Infektionen von Netzhaut und Aderhaut.

Various viral, bacterial, parasitic and fungal agents have been found to cause infections of retina and choroidea in HIV-infected patients. Usually these infections are opportunistic infections caused by the profound immunodeficiency, which is a result of the decay of lymphocytes by HIV. Before the HIV epidemic only rare cases of cytomegalovirus (CMV) retinitis were known in the literature. Now CMV retinitis has become the most common infection of the eye in AIDS patients. Ocular toxoplasmosis in HIV-infected patients can have a severe clinical appearance without treatment. Spontaneous recovery, as it usually occurs in otherwise healthy patients, does not take place in HIV-infected patients, so that a lifelong maintenance therapy is mandatory. Pneumocystis carinii chorioiditis was unknown before the HIV epidemic. In 1987 Pneumocystis carinii were found in the choroidea and two years later the clinical appearance could be described. Infections of choroidea and retina associated with AIDS may not be seen as isolated diseases. Commonly other organs are infected by the same or another organism. In case of AIDS-associated eye infections other organs should be checked for opportunistic disease. Diagnosis can be difficult. Because most of all intraocular infections associated with AIDS are CMV retinitis, an effective therapy can be initiated in most cases and in the follow-up a diagnosis can finally be made. Serological testing may be inconclusive because of occasional false-negative findings. Treatment often only suppresses the infections and so ongoing maintenance therapy may be necessary, as in the cases of CMV retinitis and Toxoplasma retinochorioiditis. A variety of different diseases, which can be treated by a multitude of different substances with a lot of adverse effects and contraindications, can complicate the therapeutic modalities used for the management of each individual disorder. Additionally HIV-infected patients suffer from at least two or three different diseases and must be treated lifelong with plenty of substances, which often are given with higher doses than usual. Only by cooperation of HIV-experienced doctors of different specialities in hospitals and offices the complex subject of HIV infection can be managed.

[Treatment of toxoplasmosis retinochoroiditis with atovaquone in an AIDS patient]. / Behandlung der Toxoplasmose-Retinochorioiditis mit Atovaquone bei einem AIDS-Patienten.

BACKGROUND: Treatment of ocular toxoplasmosis in HIV-infected patients with standard drug regimens (Pyrimethamine, Clindamycine, Sulfonamides) is very often complicated by side-effects and adverse reactions. On the other hand, maintenance therapy must be continued life long, because of the high recurrence rates. Atovaquone (Hydroxynaphthoquinon) is tolerated excellently and is very effective against tachyzoits of toxoplasma gondii and its cysts. PATIENT HISTORY AND CLINICAL FINDINGS: A 49-year-old homosexual man with AIDS developed an allergic rash after being treated with a course of Pyrimethamine and Clindamycine for unilateral, bifocal ocular toxoplasmosis for 13 days. Therapy with Atovaquone 3 x 750 mg/d was instituted and within 8 days the infiltrates healed leaving retinochorioidal scars. THERAPY AND CLINICAL COURSE: During maintenance therapy with Atovaquone (3 x 750 mg/d) two relapses occurred, the first after 2 months and the second after 8 months. The recurrences were successfully treated by increasing the dosage of Atovaquone to 4 x 750 mg/d and the addition of Trimethoprime/Sulfamethoxazol and Clindamycine/Pyrimethamine respectively. Reexposition was tolerated without an allergic reaction. Under maintenance therapy with Pyrimethamine the patient was free of recurrences for another 4 months until he died. CONCLUSIONS: Atovaquone is an effective and well tolerated substance for the treatment of ocular toxoplasmosis. In contrast to earlier reports, two recurrences occurred under maintenance therapy. It cannot be excluded that the patient was incomplient and did not take the tablets according to our prescription. Future clinical investigations have to control the efficacy of Atovaquone in the therapy of ocular toxoplasmosis.

[Mitral valve prolapse. A possible cause of retinal vascular occlusion in young patients]. / Der Mitralklappenprolaps. Mögliche Ursache retinaler Gefässverschlüsse junger Menschen.

Retinal vessel occlusion in the elderly is considered to be of arteriosclerotic etiology, but in young patients the reasons for retinal vessel occlusions are manifold and much more obscure. We report on five patients under the age of 45 years who had retinal artery occlusion or retinal vein obstruction. A detailed general investigation revealed nothing but an identical cardiac abnormality in all five cases: mitral valve prolapse (MVP). A potential explanation for the coincidence of retinal vessel occlusion and MVP might be local hyperaggregability of platelets generated by the prolapsing mitral valve. In conclusion, to prevent retinal vessel occlusion from recurring in patients with proven MVP, medication containing platelet aggregation inhibitors should be given.

Inheritance of some electrophoretic phenotypes of human hair.

Four isokeratin patterns were demonstrated by means of one-dimensional SDS electrophoresis of low sulfur proteins in human hair. The phenotypes had the following frequencies: K1 = 69.70%, K1m = 18.18%, K3 = 9.09%, K3m = 3.03%. Pedigree analysis and evaluation of observed and expected frequencies of the phenotypes gave rise to the conclusion that the phenotypes are controlled by genes of two independent autosomal loci K and m. We believe that *K3 and *m are dominant, whereas *K1 and *non-m are recessive.